Provider Contact Form

Please complete the requested information below. Note that identified fields with an asterisk (*) are required. When you are finished, click on the 'Submit' button

This form should only be used for issues unrelated to a specific claim. For questions concerning a specific claim, please use the Claims Research and Review form.

Your Information

Best time to contact you
Preferred contact method

Group Information

Authorization Information

Member Information

Group Roster Changes

If you have roster changes you may upload a file containing roster information: 

Or enter roster changes here: 

Issue Details

This form will send your message to MHN as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with MHN through email, you accept associated risks. MHN does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.