Provider Contract Request Form | Become an Iowa Total Care Provider

Thank you for your interest in joining the Iowa Total Care provider network.

To get started, please complete the form below and someone from our Network Contracting team will respond back to you within two weeks.

For all other Provider questions, please contact us.

Required fields are marked with an asterisk (*)

Contact Information

Type of Contract Request *

New Contract Amendment to Existing Contract

First Name *

Last Name *

Phone Number *

E-mail Address *

Legal Entity Name *

Attention

Provider Mailing Address *

City

County *

State

ZIP Code *

Do you have another practice location? *

Yes No

Practice Name *

Address *

City *

County *

State

Zip *

Telephone Number *

Fax Number

Entity Tax ID *

Do you have an additional Tax ID? *

Yes No

Federal Tax ID *

Federal Tax ID

Entity NPI *

Do you have an additional NPI?* *

Yes No

NPI Number *

NPI Number

Iowa Provider ID

Other *

W-9 Form Please attach your W-9 Form using the "Choose File" button