Thank you for your interest in participating with Trillium Community Health Plan. We are excited that you have selected our provider network as your network of choice. Please select the Network Participation Request Form listed below based on your specialty and services you provide. Please return this completed form, along with your W9, to our email address: NewProviderRequestBox@TrilliumCHP.com (Please note: these forms do not replace the credentialing forms/ requirements for our contractual agreements and requirements)
Network Participation Request Forms:
Physician Network Participation Request Form (PDF)
- All Medical Specialties
- Solo Practitioners
- Allied health professionals such as:
- Midwife
- Dietitian, Nutritionist
- Physician Assistant
- Medical Groups
- Multi-Specialty Medical Groups
Ancillary Network Participation Request Forms:
Ancillary Network Participation Request Form (PDF)
- Ambulatory surgery centers (ASCs)
- Dialysis facilities
- Durable medical equipment (DME)
- Home health
- Home Infusion
- Hospice
- Laboratory
- Long term acute care (LCTA)
- Orthotics and prosthetics (O&P)
- Ostomy and medical supplies
- Radiology/MRI/PET
- Skilled nursing facilities (SNF)
- Sleep study centers
Network Requests Managed by External Contractors
- Routine Vision Services
Contracting inquiries for Routine Vision Services Optometrist (OD’s) to Envolve Network Management at EBONM@EnvolveHealth.com
Network Participation Next Steps
Once you have a completed Network Participation form, please email all of the documents to the email address listed above. Someone from our contracting department will review your request for network addition/participation. A representative will be in contact with you with regarding status of this review. (Please note: If you receive a contract, there will be additional credentialing documents required to finish the contracting process.)
