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Network Participation Request Form

MHN requires a CAQH ID and a practice location in Arizona, California, Nevada, Oregon, Utah or Washington to join our network.

Required Information

* CAQH ID

I do have a CAQH ID

* CAQH ID:

I do not have a CAQH ID.

*Network State Location I have a practice location in AZ, CA, NV, OR, UT or WA
I do not have a practice location in AZ, CA, NV, OR, UT or WA

*Type of Practice:
(Select all that apply)

I'm a solo practitioner billing under an individual tax id number.

*Individual Tax ID:
Note: Please verify that the tax ID is accurate before submitting.

I'm a practitioner operating under a fictitious business name or sharing a tax ID with other practitioners or facilities.

*Fictitious Business Name:
*Fictitious Business Tax ID: Note: Please verify that the tax ID is accurate before submitting.