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  2. For Providers
  3. Join Our Network

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?:*
Do you currently accept DE Medicaid?*
Do you currently accept Medicare?*
Which line(s) of business are you interested in applying?*
Please enter the legal entity name.
Please enter the legal entity name.
Please enter the Primary Group NP.
Please enter the Primary Street Address
Please enter the City
Please enter the Zip Code
Please enter the Zip Code
Do you treat pediatric patients?*
Are you board certified?*
Is your practice a Federally Qualified Heath Center (FQHC) or Rural Health Clinic (RHC)?*
Please enter the legal entity name.
Please enter the legal entity name.
Please enter the legal entity name.
Please enter the Phone Number
Please enter the Fax Number
Please enter the Street Address
Please enter the Phone Number
Please enter the Zip Code
Please complete the CAPTCHA
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