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Provider Resource Center
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Thank you for your interest in joining the Highmark network.
We will review your request and contact you by phone or email within 12 business days. This form is for inquiry purposes only and not for official registration.
Per Delaware Health and Human Services (DHSS), all providers must be enrolled in the
DE Medical Assistance Portal (DMAP)
and have an active Provider ID.
* denotes required field
Are you currently participating with Highmark Health Options Delaware?:*
Yes
No
Do you currently accept DE Medicaid?*
Yes
No
Do you currently accept Medicare?*
Yes
No
Which line(s) of business are you interested in applying?*
Medicaid
Medicare
Both
Legal Entity Name:*
Please enter the legal entity name.
Practice Name:*
Please enter the legal entity name.
Primary Group NPI:*
Please enter the Primary Group NP.
Primary Street Address:*
Please enter the Primary Street Address
City:*
Please enter the City
State:*
Choose State
Delaware
Maryland
New Jersey
Pennsylvania
Virginia
ZIP:*
Please enter the Zip Code
County:*
Please enter the Zip Code
List specialty and sub-specialty, if applicable:
Do you treat pediatric patients?*
Yes
No
Provide hospital affiliation, if applicable:
Are you board certified?*
Yes
No
Is your practice a Federally Qualified Heath Center (FQHC) or Rural Health Clinic (RHC)?*
Yes
No
Contact Person:*
Please enter the legal entity name.
Title:
Please enter the legal entity name.
Email Address:*
Please enter the legal entity name.
Phone Number:*
Please enter the Phone Number
Fax Number:*
Please enter the Fax Number
Street Address:*
Please enter the Street Address
City:*
Please enter the Phone Number
State:*
Choose State
Kentucky
Maryland
Pennsylvania
Ohio
Virginia
West Virginia
ZIP:*
Please enter the Zip Code
Provide any additional information relevant to this request (e.g., supplemental information, special services offered, etc.):
Please complete the CAPTCHA
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