New Provider Contract Inquiry Form and Instructions

Interested in becoming a Provider in our Network?

Below are links to the instructions/requirements you will need to follow, as well as the New Provider Contract inquiry form that needs to be filled out and submitted..
  • Click on the first link to access, review, and complete the checklist. This form can also be downloaded.
  • Click on the second link to open, complete, and submit the form.

DWIHN Provider Contract Initiation Requirements (Please Read Before Completing Form)

New Contract Inquiry Form