Contract Request Form

Thank you for your interest in becoming a Carolina Complete Health Network provider.

In addition to our Standard Plan contracting, Carolina Complete Health is also currently contracting providers for physical health services with two Tailored Plans – Partners Health Management and Trillium Health Resources. View our Tailored Plan Information Guide (PDF)

Please complete the below information and one of our team members will contact you within the next 5 business days. The form below should only be used to request contracts. If you need to inquire whether a practitioner is linked to your group, notify us of any provider data discrepencies, or have other questions, reach out to your assigned Provider Network Support Specialist or email the team at: networkrelations@cch-network.com.

NOTE: Prior to contracting with Carolina Complete Health, providers must be credentialed with NC Medicaid. NCTracks is the “system of record” for provider enrollment data. View our Provider Guide: Provider Enrollment and Data (PDF) for more information.

We look forward to working with you to improve the health of the community.

Required fields are marked with an asterisk (*)

Please indicate the network(s) you would like to join: *

Carolina Complete Health Standard Plan Trillium Tailored Plan (Physical Health Providers) Partners Tailored Plan (Physical Health Providers)

First Name *

Last Name *

Phone Number *

Email Address *

Entity Tax ID *

Entity Billing NPI *

Entity Medicaid Number

Legal Entity Name *

Attention – Name/Title *

Provider Mailing Address *

City *

State *

Zip *

County *

Facility Type *

Facility/Agency Type *

W9 Form