Network Participation Request
ATTENTION: If you are currently a provider participating in one or more Health Net of California networks and are having issues registering for the new provider portal, DO NOT submit the network participation forms below.
Instead, please send an email with your contact information so a provider network representative can reach out and assist.
Thank you for your interest in obtaining an agreement for participation in the Health Net provider network. To request participation in the Health Net network:
- Identify your specialty (Practitioner or Organizational).
- Download and complete the correct participation form.
- Return your completed form to the location indicated on the form.
Network Participation Request – California
Thank you for your interest in obtaining an agreement for participation in the Health Net of California provider network. Please note that the participation request forms below apply only to physicians, licensed health care professionals and ancillary providers with practice locations in California.
The list below will assist you in determining which application applies to you or your organization. Specific instructions on submission are included within each application.
Identify your specialty (do not submit multiple forms)
California Physicians
Medical Network Participation Request Form (PDF)
To be completed for the following provider types:
- Physicians
- Urgent Care Centers
- Other licensed health care professionals including:
- PT, OT, Speech Therapist
- Dietitian, Nutritionist
- Physician Assistants
- Nurse Practitioners
- Midwifes
Behavioral Health Network Participation Request Form (PDF)
To be completed for the following provider types:
- Psychiatrists
- MFT, LCSW, PhDs
- Qualified Autism Service Providers
- Behavioral Healthcare Facilities
California Ancillary Providers
Ancillary Provider Network Participation Request Form (PDF)
To be completed for the following provider types:
- Ambulance/Transportation
- Ambulatory Surgery Center (ASC)
- Birthing Centers
- Community Based Adult Services (CBAS)
- Community Supports (CS)
- Dialysis Facilities
- Durable Medical Equipment (DME)
- Enhanced Care Management (ECM)
- Family Planning Clinics
- Hearing Aid Providers
- Home Health
- Home Infusion
- Hospice
- Intermediate Care Facility (ICF)
- Laboratory
- Long Term Acute Care (LTAC)
- Orthotics/Prosthetics (O&P)
- Ostomy & Medical Supplies
- Radiology/MRI/PET
- Skilled Nursing Facilities (SNF)
- Sleep Study Centers
Other Providers (do not submit any of the above forms)
Chiropractors or Acupuncturists
Contact American Specialty Health at 800-972-4226.