Complete the fields below to request an application to become a fully participating MassHealth provider
- Required fields need to be completed in order to process this request fully.
- Applications will be sent to the submitter 3-5 business days after this form is received. If the request cannot be processed, the submitter will be contacted.
- All correspondence will be sent to this email address.
- All applicants should avail themselves of the program regulations and participatory requirements on Mass.gov before enrollment.
All existing and applying providers should familiarize themselves with MassHealth’s regulations and provider manuals to ensure they understand the program requirements. Providers that are interested in joining the Primary Care Clinician Plan should also review PCC regulations. Providers can also register for trainings on how to complete the forms once they receive their application.
This form cannot be used to request applications for Long Term Services and Supports or dental provider types. Please refer to the Apply to Become a MassHealth Provider page in order to apply through the LTSS or Dental provider portal.