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Network Participation Request Form

PLEASE NOTE: This is not a guarantee of Contract. The information you provide is used by Sunshine Health to evaluate the offering of a Contract and is not representative of an application or a Legal Agreement. Requests are processed in the order they are received. Please allow up to fourteen (14) days for our Contracting team to review your request. A member of our team will contact you to relay if a decision is made to move forward with the contracting process within your region.

If you have not heard back within 14 days, please contact SunshineContracting@SunshineHealth.com to include the provider name and TIN. You do not need to submit a new request.

Please select your primary service type: required * Ancillary (AAC, ASC, Cochlear Implant, Dialysis, DME, Hospitalist Groups, Infusion, Laboratory/Pathology, O&P, Rehab Centers, Respiratory Groups, Voice Prosthesis, Wound Care) Behavioral Health (including Expressive Therapies - Art, Music, Equine, Pet) Hospital Long Term Care-Type Specialties (HHA, ALF, Nursing Homes) Medical or Physical Health

Error: This field is required.

Ancillary

Please select the primary county of your network participation. *

Error: This field is required.

Provider type required * Solo Practice Group Practice Facility or Agency

Error: This field is required.

Please download and fill out the forms below. Attachments required for submission

Disclosure of Ownership Form (PDF)
Contract Request Form (PDF)
W-9 Form (PDF) must be signed and dated within the last 12 months
LOAP/Practitioner Roster Form (XLSM)
Bulk LOAP/Practitioner Roster Form (XLSX)
Copy of Current Malpractice Certificate of Insurance

Please ensure that all headers marked in red on the LOAP (XLSM) document or the Bulk LOAP/Practitioner Roster Form (XLSX) for more than 50 practitioners are completed. Any missing, required information will delay the enrolment and/or credentialing process. For assistance completing our LOAP (XLSM) document, see our training video.

Provider Legal name *

Error: This field is required.

Line 1 on W-9

"Doing Business As" (DBA) Name Line 2 on W-9

TIN *

Error: This field is required.

Please no dashes "-"

Organization NPI *

Error: This field is required.

Value Based Contract Yes No

Error: This field is required.

Select if applicable

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Contract Request Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

LOAP/Practitioner Roster Form (Excel Format Only) *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Behavioral Health

Including Expressive Therapies - Art, Music, Equine, Pet

Please select the primary county of your network participation. *

Error: Select the primary county

Provider type required * Psychiatric Hospital CSU/ST RTF Residential Treatment Center Substance Abuse Rehabilitation Center Community Mental Health Center Solo Practice – BH Outpatient Group Practice – BH Outpatient Expressive Therapies - Art, Music, Equine, Pet

Error: Select provide type

Please download and fill out the forms below. Attachments required for submission

Disclosure of Ownership Form (PDF)
BH Contract Request Form (PDF)
W-9 Form (PDF) must be signed and dated within the last 12 months
LOAP/Practitioner Roster Form (XLSM)
- CHMC’s – required to have MD/DO on staff and listed on LOAP
Bulk LOAP/Practitioner Roster Form (XLSX)
Copy of Current Malpractice Certificate of Insurance

Please ensure that all headers marked in red on the LOAP (XLSM) document or the Bulk LOAP/Practitioner Roster Form (XLSX) for more than 50 practitioners are completed. Any missing, required information will delay the enrolment and/or credentialing process. For assistance completing our LOAP (XLSM) document, see our training video.

Provider Legal name *

Error: This field is required.

Line 1 on W-9

"Doing Business As" (DBA) Name Line 2 on W-9

TIN Please no dashes "-"

Organization NPI

Value Based Contract Yes No

Error: This field is required.

Select if applicable

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Contract Request Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

LOAP/Practitioner Roster Form (Excel Format Only) *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Hospital

Please select the primary county of your network participation. *

Error: This field is required.

Please download and fill out the forms below. Attachments required for submission

Disclosure of Ownership Form (PDF)
Contract Request Form (PDF)
W-9 Form (PDF) must be signed and dated within the last 12 months
LOAP/Practitioner Roster Form (XLSM)
Bulk LOAP/Practitioner Roster Form (XLSX)
Copy of Current Malpractice Certificate of Insurance

Please ensure that all headers marked in red on the LOAP (XLSM) document or the Bulk LOAP/Practitioner Roster Form (XLSX) for more than 50 practitioners are completed. Any missing, required information will delay the enrolment and/or credentialing process. For assistance completing our LOAP (XLSM) document, see our training video.

Provider Legal name *

Error: This field is required.

Line 1 on W-9

"Doing Business As" (DBA) Name Line 2 on W-9

TIN *

Error: This field is required.

Please no dashes "-"

Organization NPI *

Error: This field is required.

Value Based Contract Yes No

Error: This field is required.

Select if applicable

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Contract Request Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

LOAP/Practitioner Roster Form (Excel Format Only) *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Long Term Care-Type Specialties

Please select the primary county of your network participation. *

Error: This field is required.

Provider type required * Skilled Home Health Agency Non-Skilled Home Health Agency Assisted Living Facility Nursing Home Adult Day Care Adult Family Care Home Home Delivered Meals Pest Control Personal Emergency Alert Nurse Registry

Error: This field is required.

Please download and fill out the forms below. Attachments required for submission

LTC-Specialty Contract Request Form (PDF)
W-9 Form (PDF) must be signed and dated within the last 12 months
Copy of Current AHCA License

Provider Legal name *

Error: This field is required.

Line 1 on W-9

"Doing Business As" (DBA) Name Line 2 on W-9

TIN *

Error: This field is required.

Please no dashes "-"

Organization NPI *

Error: This field is required.

Value Based Contract Yes No

Error: This field is required.

Select if applicable

Type of Service *

Error: This field is required.

Servicing Counties *

Error: This field is required.

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Contract Request Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Copy of Current AHCA License *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Medical or Physical Health

Please select the primary county of your network participation. *

Error: This field is required.

Provider type required * Solo Practice Group Practice Facility or Agency

Error: This field is required.

Please download and fill out the forms below. Attachments required for submission

Disclosure of Ownership Form (PDF)
Contract Request Form (PDF)
W-9 Form (PDF) must be signed and dated within the last 12 months
LOAP/Practitioner Roster Form (XLSM)
Bulk LOAP/Practitioner Roster Form (XLSX)
Copy of Current Malpractice Certificate of Insurance

Please ensure that all headers marked in red on the LOAP (XLSM) document or the Bulk LOAP/Practitioner Roster Form (XLSX) for more than 50 practitioners are completed. Any missing, required information will delay the enrolment and/or credentialing process. For assistance completing our LOAP (XLSM) document, see our training video.

Provider Legal name *

Error: This field is required.

Line 1 on W-9

"Doing Business As" (DBA) Name Line 2 on W-9

TIN *

Error: This field is required.

Please no dashes "-"

Organization NPI *

Error: This field is required.

Value Based Contract Yes No

Error: This field is required.

Select if applicable

Contact Name

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Contract Request Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Disclosure of Ownership Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

LOAP/Practitioner Roster Form (Excel Format Only) *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

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Sunshine Health is a managed care plan with a Florida Medicaid contract. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change. For more information contact the Managed Care Plan.

Sunshine Health

P.O. Box 459089
Fort Lauderdale, FL 33345-9089

Phone: 1-866-796-0530
TTY: 1-800-955-8770
Monday-Friday 8 a.m.-8 p.m. Eastern

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

Sunshine Health is a managed care plan with a Florida Medicaid contract. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change. For more information contact the Managed Care Plan.

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