Contract Request Form

Thank you for your interest in joining the Virginia Total Care provider network. We are currently accepting:

  • New Contracts for Medicare contracting 
  • LOA for Medicaid

To get started, please complete the form below and a representative from our Network Contracting team will respond back to you shortly.

For all other Provider questions, please contact us.

Contract and LOA Request Form

Type of Request *
Production Section *

Provider Information

Provider Identification Numbers

W-9 Form Please attach your W-9 Form using the "Choose File" button

*If you do not attach a W-9 now, you may be required to supply one later

Provider Forms