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California Network Participation Request

Network Participation Request – California

Thank you for your interest in participation in the Health Net of California provider network. Please note that the following participation request forms apply only to California licensed physicians, health care professionals, behavioral health facilities and ancillary providers.

Request to Add or Remove Practitioners or Sites from Your Existing Health Net Contract

Providers who are already directly contracted with Health Net can update information via the Participating Provider Operations page.

Providers contracted under a PPG should contact their PPGs to update their information.

Application Instruction to Physicians/Licensed Health Care Professionals

Please note that completion of this Network Participation 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 be rejected.
  • Application processing and provider credentialing may take 90 to 120 days after a completed Network Participation Request and all required information has been received.
  • Health Net participates with the Council for Affordable Quality Healthcare (CAQH) Universal Credentialing DataSource. For more information visit visit CAQH.

The following list will assist you in determining which application applies to you or your organization. Specific instructions on submission are included within each application.

Participation Request Form

* indicates a required field.

California Professional Providers / Behavioral Health Entities

Step 1: Choose a Provider Type

MEDICAL / BEHAVIORAL HEALTH PROVIDER required *
  • Physicians
  • Urgent Care Centers
  • Psychiatrists
  • MFT, LCSW, PhDs
  • Qualified Autism Service Providers
  • Behavioral Healthcare Facilities
  • Other licensed health care professionals including:
    • PT, OT, Speech Therapist
    • Dietitian, Nutritionist
    • Physician Assistants
    • Nurse Practitioners
    • Midwifes
Ancillary Provider required *
  • Ambulance/Transportation
  • Ambulatory Surgery Center (ASC)
  • Birthing Centers
  • Community Based Adult Services (CBAS)
  • Community Supports (CS)
  • Dialysis Facilities
  • Durable Medical Equipment (DME)
  • Enhanced Care Management (ECM)
  • Family Planning Clinics
  • Hearing Aid Providers
  • Home Health
  • Home Infusion
  • Hospice
  • Intermediate Care Facility (ICF)
  • Laboratory
  • Long Term Acute Care (LTAC)
  • Orthotics/Prosthetics (O&P)
  • Ostomy & Medical Supplies
  • Radiology/MRI/PET
  • Skilled Nursing Facilities (SNF)
  • Sleep Study Centers

 

Step 2: Medical / Behavioral Health Providers Form

I Am / We Are:
Applying as:

Renegotiation Information

Physician/Provider Information

Gender required *
Expiration Date: Is license due to expire within 3 months of submission?
Telehealth required *

Group Information

Telehealth required *

Behavioral Health Facility

Behavioral Health Facility Type

Behavioral Health Facility Type

Primary Practice Address

Person to Contact about this Request

I am a third-part consultant engaged on behalf of a provider.

To add providers / sites to your existing contract, please go to the Participating Provider Operations page. 

Note: Health Net requires the provider's confirmation of your authorization and a signed non-disclosure agreement before substantive discussions begin; the required documents will be supplied by Health Net.

Step 2: Ancillary Providers Form

Medicare Certified
Medi-Cal Participant

Practice Address

Multiple Locations?

Person to Contact about this Request

Ancillary Specialties – Transportation

Thank you for reaching out and expressing your interest in contracting with Health Net of California, Inc. I wanted to let you know that at this time, Health Net is not pursuing direct contracting with Ambulance/Transportation providers. Our network is currently closed due to our existing contract with Modivcare.

If you are interested in contracting opportunities, please contact Operations at Modivcare. You can reach Modivcare by email at Ca.Operations@modivcare.com or by phone at (657) 441-3910.

We appreciate your inquiry and your interest in working with Health Net.

Ancillary Specialties – Hospice

Thank you for reaching out and for your interest in contracting with Health Net of California, Inc. Health Net’s hospice panel is closed to new hospice providers, and we are not currently pursuing direct contracting for hospice services.

We appreciate your interest and encourage you to reconnect in the future should our contracting strategy change.

Other Providers (do not submit a form)

Chiropractors or Acupuncturists

Last Updated: 11/02/2026