Join Our Network Form

Non-Contracted Providers

If you are a non-contracted provider, please select the “Join Our Network” tab to begin your request. (See “Join Our Network Form” reference below)

Contracted Providers

To update your existing demographic information (address, email, telephone number, etc.) visit the Contact Us page.

To add practitioners to your participating location, download the required forms listed below and submit to IHPAContracting@EnvolveHealth.com.

Contract Questions

If you have other questions regarding your IHPA contract call us toll free at 1-844-298-6981 or email us at IHPAContracting@EnvolveHealth.com.

Disclaimer: Your request for participation is not a guarantee of Contract. The information you provide is used by the Illinois Health Practice Alliance 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. Reviews will be performed within one (1) business week. 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 are not contracted with Illinois Health Practice Alliance, complete the Network Participation Request Form below.

* Required Fields

Please select your primary service type: *

Ancillary (FQHC’s providing Behavioral Health Services) Behavioral Health (Outpatient Only) Behavioral Health (In-Patient w/ or w/out Outpatient)

Provider Type *

Solo Practice Group Practice Facility or Agency

Provider Type *

Psychiatric Hospital CSU/ST RTF Residential Treatment Center Community Mental Health Center Substance Abuse Rehabilitation Center

Please include the primary county of your network participation.

Provider Legal name *

Line 1 on W-9 - "Doing Business As" (DBA) Name

Line 2 on W-9

TIN *

Organization NPI *

Contact Name *

Contact Phone *

Contact Email *

Please download and complete the forms below. Attachments are required for your submission.

Contract Request Form *

W-9 Form *

Universal Roster (Excel) *

Illinois Health Practice Alliance maintains criteria and processes to credential the following practitioners:

Medical Doctor (MD)
Doctor of Osteopathic Medicine (DO)
Advanced Practice Registered Nurse (APRN)
Advanced Registered Nurse Practitioner (ARNP)
Board Certified Behavior Analyst (BCBA Certification)
Comprehensive Behavioral Health Assessor (CBHA Certification required)
Clinical Nurse Specialist (CNS)
Licensed Clinical Social Worker (LCSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Mental Health Counselor (LMHC)
Licensed Psychologist (LP)
Nurse Practitioner (NP)
Physician Assistant (PA)
Registered Nurse (RN)

Illinois Health Practice Alliance maintains criteria and processes to credential the following provider types:

Community Mental Health Center (CMHC)
Federally Qualified Health Center / Rural Health Center (FQHC/ RHC)
Intensive Family Intervention (IFI)
Rehabilitation Center (RC)
Substance Use Treatment Facility

Contract Questions

If you have other questions regarding your IHPA contract email us at IHPAContracting@EnvolveHealth.com.