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Contract Request Form

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 30 business days to analyze the form and make a determination if the contract process will commence. Failure to accurately complete the form will significantly extend this processing time. 

We will outreach to the contact person listed once a review of your data is completed. If you have any questions or are in need of additional information, please contact Meridian Contracting at MIProviderContracting@mimeridian.com

Authorization is required if you need to treat a Meridian Medicaid member prior to being contracted. Our Medical Management department will review the member’s needs with you and issue an Authorization as needed if a contracted provider is not available to provide the services. Medical Management does coordinate with our contracting department when a non-contracted provider receives an Authorization.

Provider Credentialing Rights
During the credentialing process, Meridian obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling your health plan Provider Relations Representative.

Contact Information

Contract Status required *

orange alert iconIMPORTANT NOTE: Duplicate requests to this form will not be processed.

If you would like to verify a previous contract form submission, please reach out to MIProviderContracting@mimeridian.com and provide the following information so we can confirm your request:

  • Practice Name
  • Tax ID
  • Requester Name
  • Contact Email Address
  • Submission Date (if available)

orange alert iconIMPORTANT NOTE: This form does not route to Practitioner Enrollment, only new contracts.

If you would like to add a practitioner to an existing contract, please utilize our Practioner Enrollment Form to ensure your request is routed correctly.

Provider Type

Select your provider type. required *
Do you bill on a UB or a 1500 form? required *

Product Interest

Select the products you want to participate in. required *

Provider Information

Enter the county in Michigan your practice is located in, or enter "Out of State"
Applying as: required *
Is this your primary specialty? required *

Provider Identification Numbers

Review & Submit

Last Updated: 05/27/2025