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Add to Group Online Form

Add Provider to an Existing Group Contract

Health Net is committed to giving our providers the best tools to support their administrative needs. We have created an easy way for you to add additional providers to existing contracts by completing the following form.

Application Instruction to Physicians/Licensed Health Care Professionals:

This form is for providers with existing contracts. If you are not a participating provider with Health Net and want to apply, please go to our Network Participation Request page.
Please note that completion of this Add to Group Request Form and/or credentialing application does not guarantee acceptance in the Health Net provider network.
Health Net will review your request to ensure you meet initial participation criteria, including maintaining admitting privileges at a Health Net network hospital.
Complete all required fields. Incomplete forms will not be considered.
Application processing and provider credentialing may take 90 to 120 days after a completed Add to Group Form and all required information has been received.
Health Net participates with the Council for Affordable Quality Healthcare (CAQH) Universal Credentialing DataSource, which can simplify your application process. If you participate with CAQH, please indicate your ID # in the form. If you do not participate, a Health Net representative will assist you during the process. For more information, and a demonstration, visit CAQH.
This form is for adding one practitioner. To add multiple direct network practitioners, email us at DNPNM_DVP@healthnet.com.
For questions about adding a provider to an existing group, email us at DNPNM_DVP@healthnet.com.

For all other questions, contact us.

Network Participation Request
Medical Policies
EDI
Participating Provider Operations Information
Add to Group Online Form
Provider Payment Options
Provider Demographics Update Form

* indicates a required field.

Affiliation Type required * Direct Network (Directly contracting with Health Net) Participating Provider Group (PPG)

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Attach W-9 *

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Applying as: *

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Hold Ctrl to Select more than one

Practitioner Information

Practitioner First Name *

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Practitioner Middle Initial

Practitioner Last Name *

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Suffix

Degree/Certification *

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Date of Birth *

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Gender required * Male Female

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National Provider Identifier (NPI) *

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Medical School (PCP only)

Graduate Year *

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CA DEA #

CA DEA Expiration Date

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Expiration Date: Is license due to expire within 3 months of submission? Yes No

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Attachment: License Renewal Copy *

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CAQH ID (if applicable)

Telehealth required * In Person Telehealth Only Telehealth and In Person

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Practice Address

Address *

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City *

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State *

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ZIP *

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Practice Telephone Number *

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Practice Fax Number

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Office Hours

Display in the Directory? Yes No

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Status Accepting New Patients Prior Patients Only

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Would you like to add additional practice addresses? required * Yes No

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Additional Practices Template

Please list additional addresses: Download the template, fill it out and upload.

Additional Practice Address Template (XLSX)

Upload Additional Practices Address file

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Is Mailing Address different than practice address? required * Yes No

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Mailing Address *

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City *

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State *

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ZIP *

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Is Remittance Address different than practice address? required * Yes No

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Remittance Address *

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City *

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State *

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ZIP *

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Primary Specialty *

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Board Certification Date (if applicable)

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CA License # *

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License Type

Secondary Specialty

Board Certification Date (if applicable)

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CA License #

License Type

Provider Group Information

Group Name Tax Title *

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Group NPI *

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Tax ID *

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Adding Extenders? required * Yes No

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Supervising Provider Name *

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Supervising Provider License # *

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Please list your Hospital Affiliations (or Covering Physicians) if applicable

Hospital Privileges

Medi-Cal Applicable? required * Yes No

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Medi-Cal Line of Business

Medi-Cal Training attestation *

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Items in the trash will be permanently removed after 30 days.

DHCS Letter of Approval

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Medi-Cal ID *

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Limit by Age *

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Limit by Gender *

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Medicare Applicable? Yes No

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Medicare Line of Business

Medicare Approval Letter

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Behavioral Health Line of Business

Please check any of the following focuses that apply to your practice. You may select up to 20. *

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Hold Ctrl to select multiple

Person to Contact about this Request

Person to contact regarding this request *

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Contact Phone *

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Contact Email *

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Participating Provider Group (PPG)

Please reach out to your PPG to add additional providers.
Contact us if you have questions.

Last Updated: 05/20/2026

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AG SETTLEMENT / PROVIDER DIRECTORIES

Health Net has made enhancements to our online Provider Directory in order to better serve our members in conjunction with work with the California Attorney General’s Office and the San Diego City Attorney. Learn more here (PDF)

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Health Net collects some private data about site visitors. Learn more about the data we collect or request your data be removed.

AG SETTLEMENT / PROVIDER DIRECTORIES

Do Not Sell My Personal Information

Choosing Who Can See My Confidential Medical Information

© Copyright 2026 Health Net of California, Inc., Health Net Life Insurance Company, and Health Net Community Solutions, Inc. (Health Net) are subsidiaries of Health Net, LLC. and Centene Corporation. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. Health Net is a registered service mark of Health Net, LLC.