Provider Enrollment

Initial Enrollment Forms | Change Forms | Hospital Forms | Questions | Endorsement

Notice: As a waiver site WHN is no longer offering contracts to all interested providers, but will enroll providers based on the needs of the local recipients and on provider network performance. WHN became an operational waiver site as of January 3, 2012. WHN held its open enrollment period during the implementation of its 1915 b/c waiver, from April 2011 through December 2011. 

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Special Medicaid Bulletin from DMA (April 2012)

Insurance Requirements - General (8/24/11)

Insurance Requirements - Licensed Invidual Practitioners (Bulletin #111)  (March 3, 2012)

Sample Contracts for review - 1915 b/c Waiver (8/25/11)

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Initial Enrollment Forms:

Providers who would like to enroll with Western Highlands Network (WHN) must first submit a Provider Enrollment Application Request Form.

Provider Enrollment Application Request Form | Instructions

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Change Forms:

 Request to Add/Change/Remove Site
 

Request to Add a Licensed Practitioner For a currently contracted agency to add a new practitioner.  (Updated 3/12/12)

• Provider Evaluation Form (posted 3/26/12) 

• Credentialing Initiation Form Practitioners already credentialed by WHN may submit the Credentialing Initiation Form to be added as  new employee/contractor with an additional agency. (posted 5/3/12)
  

Request to Change Ownership (posted 3/7/12) 

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Hospital Forms:

Contract Application for Hospital Based Inpatient and Outpatient Psychiatric Services (updated 5/17/12)

Hospital Based Psychiatric Inpatient and Outpatient Licensed Registration Worksheet

 Letter of Attestation for False Claims Act Education

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Endorsement:

Triennial Re-Endorsement Attestation

Business Verification Letter of Attestation

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Questions? This e-mail address is being protected from spambots. You need JavaScript enabled to view it

We respectfully request that all enrollment inquiries be submitted through the above link or call 800-671-6560 ext 2469 so that we may manage volume and route inquiries appropriately.

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