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)


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 discrepancies, 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. NC Tracks 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 (*)

 

PICK ALL THAT APPLY:

Please indicate all the network(s) you would like to join.

 
 
 
Phone
 
 
 
 

Note: Must match W9 and NC Tracks

 

Note: Must match W9 and NC Tracks

 
 
 
 
 
 

Please attach a copy of your W9.

Drop your files here