Provider Interest Form

Please complete the fields listed below. Once we receive the completed form, a Valley Health Plan ambassador will contact you within 15 business days.

Please Note: 

Valley Health Plan contracts are determined by member need for services. Any interested providers who are inclined to take all the Lines of Business listed below will be given precedency in the review process. 

Provider Interest Form

Which network are you interested in participating? (please check all that apply)
Name and Degree
Primary Office Address

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