Letter of Interest Form - Beacon Health Strategies 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Provider Name/Legal Entity Name as it appears on your W-9. If you are a different requesting individual, fill in that information next.
3. Provide the date of submission and list all relevant Licensure(s) such as LICSW, MD, or LMHC.
4. Fill in your Tax Identification Number (TIN) and NPI. Ensure these numbers are accurate to avoid processing delays.
5. Complete the Practice Address and Mailing Address fields, followed by your Phone Number and Fax Number.
6. Indicate your Medicare and Medicaid Numbers, if applicable, along with any languages spoken.
7. Detail your Availability (hours) and Years of Experience in Private Practice. Be specific about the Description of Services you offer.
8. Finally, ensure you have attached a completed W-9 form for consideration before submitting via email to provider.relations@beaconhs.com.

Start filling out your Letter of Interest Form today using our platform for free!