Become a Provider

Thank you for your interest in joining 22 Health’s Provider Network. To start the credentialing process, complete the Letter of Interest (LOI) form and follow the submission instructions.

Become a Provider

Thank you for your interest in joining 22 Health’s Provider Network. To start the credentialing process, complete the Letter of Interest (LOI) form and follow the submission instructions.

Are You Currently a Contracted Provider?

Contracted Providers

To add your facilities including Ancillary, Behavioral Health, and Hospital providers to your existing participating contract:

Please download and complete our
HDO Application  and email it to

providersupport@22healthplan.com

To add practitioners to your current contract:

Please download and complete our Provider Data Form, Provider Roster Template, and a W-9 Form dated within the last 12 months and email it to providersupport@22healthplan.com

To Become a Provider

Thank you for your interest in joining 22 Health’s Provider Network. 22 Health is an entity owned and operated by South Florida’s most experienced names in healthcare: Broward Health (North Broward Hospital District) and Memorial Healthcare System (South Broward Hospital District) in Broward County.

To start the credentialing process, please complete the Letter of Interest (LOI) form below and follow the submission instructions. Once this information is received, you will be notified by 22 Health of the next steps in the credentialing process. Credentialing connects you with a growing network of professionals across Florida, whose qualifications are carefully vetted and approved to distinguish the network as one that is committed to quality across all standards of care.

Contracting Contact Name:

Contracting Contact Email:

Contracting Contact Phone:

Credentialing Contact Name:

Credentialing Contact Email:

Credentialing Contact Phone:

Group Name (as appears on W9)

Doing Business As (DBA) Name:

Tax ID:

Billing/Group NPI:

Specialty:

Scope of Services:

Group Medicaid ID:

Age Range:

Primary Address:

City:

State:

Zip Code:

Corporate Address (if applicable):

City:

State:

Zip Code:

Practice Website:

EMR Name:

After hours coverage:

Telemedicine Services:

Board Certified:

Patient Centered Medical Home (PCMH):

PCMH Accreditation/Recognition Program:

NCQA Behavioral Health (BH) Integration Distinction:

NCQA Patient Centered Specialty Practice:

Interested in delegated credentialing?

QUICK LINKS