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Contract Request Form

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.

Are you already contracted? If so, please visit our Forms & Resources section for a list of our forms to make changes/additions.

Required fields are marked with an asterisk (*)

Contact Information

Type of Contract Request required * New Contract Amendment to Existing Contract

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First Name *

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Last Name *

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Phone Number *

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E-mail Address *

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Provider Information

Legal Entity Name *

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Attention

Provider Mailing Address *

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City

County *

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State

ZIP Code *

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Contract Mailing Preference *

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Do you have another practice location? required * Yes No

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Practice Name *

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Address *

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City *

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County *

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State

Zip *

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Telephone Number *

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Fax Number

Provider Identification Numbers

Entity Tax ID *

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Do you have an additional Tax ID? required * Yes No

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Federal Tax ID *

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Federal Tax ID

Federal Tax ID

Federal Tax ID

Federal Tax ID

Entity NPI *

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Do you have an additional NPI?* required * Yes No

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NPI Number *

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NPI Number

NPI Number

NPI Number

NPI Number

Iowa Provider ID

Provider Type required * Physician Group or Individual Practitioner Behavioral Health Practitioner Ancillary or Hospital Based Practitioners Vision Provider Long Term Supports and Services Acute Care Hospital Federally Qualified Health Center Rural Health Center Community Mental Health Center I/T/U Other

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Other *

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W-9 Form

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

Items in the trash will be permanently removed after 30 days.

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