Request An Application:

Providers wishing to become participants in our preferred network should follow the steps in the Request an Application questionnaire. Doing so will provide the Midlands Choice contracting department with information needed to forward the appropriate contract and application to the requestor to complete and return to Midlands Choice.

To more quickly identify your needs and better facilitate your request, we will first ask you a short series of questions about your practice or facility.

Is this application for a hospital or an ancillary facility (e.g. Alcohol/Drug Center, Ambulance Service, Ambulatory Surgery, Dialysis Centers, Durable Medical Equipment, Home Health Care, Hospice, Hospitals, Infusion Therapy, Laboratory, Prosthetics/Orthotics, Radiology Center, Sleep Disorder or Urgent Care)?