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Note: Items with * are required information.

First Name*
Last Name*
Practice Name*
Position or Role
Email Address
Email Confirmation
Address
Address 2 (Suite, Bldg., etc.)
City
State
Zip

Service Delivery Area (SDA) (Click here to find your SDA)
Note: If your practice is in more than one SDA, please choose the SDA for your main office.
 
Products* (please select all that apply)
 Allwell from Superior HealthPlan (HMO)
 Allwell from Superior HealthPlan (HMO SNP)
 Ambetter from Superior HealthPlan - Health Insurance Marketplace
 CHIP/CHIP Perinate
 STAR
 STAR Health
 STAR Kids
 STAR+PLUS
 STAR+PLUS Medicare-Medicaid Plan (MMP)

Specialty Type
(please select all that apply)
 Behavioral Health
 Cardiology
 Durable Medical Equipment (DME)
 Endocrinology
 Hospital
 Long-Term Services and Supports (LTSS)
 Nursing Facility
 OB/GYN
 Therapy (Physical/Occupational/Speech)
 Pharmacy
 Pediatrics
 Primary Care Provider (PCP)
 Pulmonology
Other (if specialty is not listed above, please enter specialty type)

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