Join Our Network

Join our network by completing this form.

If your practice is already contracted with Gateway Health but need to make a change, like one of the changes listed below, please complete the Practice Change form.
• Address Changes;
• Phone & Fax number changes;
• Changes of hours of operation;
• Primary Care Practice (PCP) panel status changes (Open, Closed & Existing Only);
• Practitioner participation status (additions & terminations) and;
• Mergers and acquisitions.

If your practice is already contracted with Gateway Health but need to add a new physician please complete the Provider Data Form to initiate Credentialing.

If you are a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) please complete a roster whenever you have New Adds, Demographic changes and Terminations occur within your FQHC/RHC practice location(s). Roster template

Please email the completed roster to: [email protected].

Are you currently participating with Gateway? * Yes No

Which Line(s)-of-Business are you interested in applying for? * Medicaid Medicare Both Medicaid Provider Manual
Medicare Provider Manual

Do you currently accept PA Medicaid? * Yes No Per our HealthChoices Agreement (HCA) we are required to ensure that all providers operating within the PH-MCO’s network who provide services to recipients must be enrolled in the Commonwealth’s MA program and possess an active MMIS Provider ID for each location in which they provide services to our members.

Do you currently accept Medicare? * Yes No Active participation in the Medicare and/or Medical Assistance Programs; free of sanctions.

Legal Entity Name:* Practice Name*: Primary TIN*: Primary Group NPIs Linked to TIN*: Primary Street Address: City:* State* Zip Code:* County:* Specialty*

Is your practice a Federally Qualified Heath Center (FQHC) or Rural Health Clinic (RHC)?: * Yes No

Hospital Affiliation:

Are you Board Certified?: * Yes No

Contact Person:* Title: Email Address:* Phone Number:* Fax Number:* Contact’s Address, City, State & Zip:*