Join Our Network | Ambetter from Magnolia Health


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If your business offers Behavioral Health Services, please complete our Behavioral Health Contract Request Form. Providers offering both Physical Health Services and Behavioral Health Services must complete both forms.

Required fields are marked with an asterisk (*)

Provider Request Information (please select all that apply)*
Which product line(s) do you currently participate in?
Which product line(s) are you requesting to enroll in?
*Must have valid MS Medicaid ID to participate in MississippiCAN


Contact Information

Contact Name

Provider Information

Provider Identification Numbers

Type of Provider (Please check all that apply)*