Provider Email Address Collection

Seeking Email Addresses

In an effort to improve the quality, relevance, and timeliness of provider communications, Health Net has moved from fax and hard copy notifications to email. Please complete the form below. You may submit as many contacts as are appropriate for your practice.

Thank you for helping us to be more nimble and responsive to our providers’ needs.

Practice Name *

Contact Name *

Job Title

Phone Number

Email Address *

Additional Email Address

Preferred Mailing Address *

Physical Address (if different from Mailing Address)

Group NPI

TIN

Provider Type * PCP Specialist

What is Specialty? *

Line of Business (Check all that apply) * MA PPO MA HMO Commercial

Do you also accept Trillium OHP/Medicaid? * Yes No