Join Our Network | Ambetter from Magnolia Health

If your business offers Behavioral Health Services, please complete our Behavioral Health Contract Request Form. Providers offering both Physical Health Services and Behavioral Health Services must complete both forms.

Required fields are marked with an asterisk (*)

Provider Request Information (please select all that apply)*

New applicant or current participating provider requesting to join product networks managed by Magnolia Health Current Participating Provider requesting to change name or Tax Identification Number (TIN)

Which product line(s) do you currently participate in?

Mississippi Coordinated Access Network (MississippiCAN) Commercial Exchange (Ambetter) Medicare Advantage (Allwell)

Which product line(s) are you requesting to enroll in?

Mississippi Coordinated Access Network (MississippiCAN)* Commercial Exchange (Ambetter) Medicare Advantage (Allwell) *Must have valid MS Medicaid ID to participate in MississippiCAN

Please provide sufficient detail, i.e Change of ownership: Changing name and TIN

Contact Information

Contact Name

First *

Last *

Contact Phone Number *

Contact E-Mail Address *

Provider Information

Legal Entity Name *

ATTN *

Street Address *

City *

State *

ZIP Code *

Provider Identification Numbers

Provider Name *

Group TIN *

Group NPI *

Group Medicare Number

If "Other" was selected, please list type of provider here

Does your office meet Americans with Disabilities Act (ADA) requirements for accessibility?

Yes No

Do your physicians/practitioners speak a language other than English? If so, what language?

Yes No

Is language interpretation available in your office?

Yes No

W9 *