Join Our Network

Network Participation Request

Thank you for your interest in joining our network. Completion of the below application form indicates your interest only. Your inquiry will be evaluated based on the needs our membership in your practice area. You will be contacted by our Network Development and Contracting Team regarding your request. Please allow 2-3 business days for our evaluation and response.

Required fields are marked with an asterisk (*)

Are you currently contracted with an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO)? * Yes No

Select Your Primary Specialty *

Enter Group Practice Name *

Enter Provider Tax ID Number (e.g. 999999999) *

Enter Provider NPI Number *

Enter Group NPI Number

Primary Practice Address *

City *

State *

Zip Code *

County

Contact Name *

Contact Number *

Contact Email *

Agreement * I understand this inquiry does not guarantee my participation in the Ambetter from WellCare of Kentucky Plan network.

Agreement * I understand that failure to complete this inquiry accurately and completely will result in the delay of evaluating my request.

Thank you for your interest in participating in the Ambetter from WellCare of Kentucky network! If you would like to receive more information on becoming a provider within our network or would like to receive a contract, please contact us at 1-833-705-2175.

Become An Ambetter Provider in Kentucky | Ambetter from WellCare of Kentucky

Join Our Network

Network Participation Request