Provider Participation Request

Health Choices contracts with physicians and providers to provide services to our members that reside in Iowa, Nebraska, Illinois, and Wisconsin. If you are interested in participating in our provider network, please fill out the form and a Health Choices representative will contact you once the request has been reviewed. The review process could take up to 30 days depending on scheduling. If you do not receive a response after 30 days, please send an e-mail to cwilwert@mahealthcare.com to request an update on your request.

Provider Participation Request

Facility or Office Name*
Practitioner Name*
First Last
Title/Degree
Contact Person*
Email*
Phone*
Street Address*
Address Line 2
City
State / Province / Region
Zip / Postal Code
Primary Specialty
Secondary Specialty
Participating in Medicare
- Yes
- No
Certifications*
- Board Certified
- Board Eligible
- Not Applicable
Effective Date
MM slash DD slash YYYY
NPI#
Tax ID#
CAQH ID#
Other Information