Join Our Network

Are you currently participating with Highmark Health Options Delaware?

Yes

No

Do you currently accept DE Medicaid?

Yes

No

Do you currently accept Medicare?

Yes

No

Which line(s) of business are you interested in applying?

Medicaid

Medicare

Both

Legal Entity Name

Practice Name

Primary Group NPI

Primary Street Address

City

ZIP Code

County

List specialty and sub-specialty, if applicable:

Do you treat pediatric patients?

Yes

No

Provide hospital affiliation, if applicable:

Are you Board Certified?

Yes

No

Is your practice a Federally Qualified Heath Center (FQHC) or Rural Health Clinic (RHC)?

Yes

No

Contact Person

Title

Email Address

Phone Number

Fax Number

Street Address

City

ZIP Code

Thank you for your interest in joining the Highmark Health Options Delaware network.