Contact Email Form

Request Information to enroll as a new provider

For more information on how to become a participating Provider with Gateway Health Plan^®, please complete the required fields below with your name, specialty, state, e-mail address, and telephone number with area code. Click the Send button. You will receive a message saying that a representative will contact you shortly. We look forward to speaking with you! If you are already a Gateway Health Plan^® provider and have a question or need assistance, please call the Provider Services Department.
PA Medicaid: 1-800-392-1145
PA and OH Medicare: 1-800-685-5205

* Physician/Provider Name
Practice Name
Hospital Affiliation
* Specialty
Contact Person
Street Address
* City
* State
Zip
* County
* Email Address
* Phone Number	ex. 999-999-9999
Do you currently accept Medicaid?	YesNo
Do you currently accept Medicare?	YesNo
Are you Board Certified?	YesNo