The Facility Notification Form is for our participating providers that are currently in our network. If your facility is interested in joining our network, please complete the
Provider Participation Request Form
We recommend using one of the following browsers: Chrome, Edge, or Firefox to complete
the Facility Notification Forms.
Select this option when a new clinic/hospital location needs to be added to an existing participating provider.
Select this option to update information related to an existing participating facility location. Complete this form for changes to the facility phone or fax number, if the facility is relocating and/or there is an address change.
Select this option when a clinic is closing.