Provider Intake Form
Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 20 business days to analyze the form and make a determination if the contract process will commence. Failure to accurately complete the form will significantly extend this processing time.
We will outreach to the contact person listed once a review of your data is completed. If you have any questions or are in need of additional information, please contact the Contracting Department at email@example.com.
Authorization is required if you need to treat a YouthCare Health member prior to being contracted. Our Medical Management department will review the member’s needs with you and issue an Authorization as needed if a contracted provider is not available to provide the services. Medical Management does coordinate with our contracting department when a non-contracted provider receives an Authorization.