Contract Request Form (PDF) - Magnolia Health Plan 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by selecting your provider type from the options provided. You can choose multiple types that apply to your organization.
  3. Fill in the Group Information section, including the Group Name, Primary Physical Address, and contact details such as Phone and Email.
  4. Complete the Hours of Operation by indicating your availability for each weekday.
  5. Provide your Group Medicaid #, Medicare #, TIN #, and Billing NPI# in the respective fields.
  6. If applicable, include information about your Credentialing Contact Person and their contact details.
  7. Answer the ADA compliance question and indicate if any physicians speak languages other than English.
  8. Add any additional notes in the designated area at the bottom of the form.

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