Request to Join Our Network

  2. Providers
  3. Join our Network
  4. Request to Join Our Network

Provider Form

Please fill out the form below so that we may begin your credentialing process. All providers must have a currently attested CAQH application to begin the credentialing process with First Choice Health. If your CAQH application is not current, DO NOT complete this form until it is current.

Helpful Tips:

  • If you experience any issues filling out the form, please make sure you use the Chrome browser and avoid using any autofill features.
  • Zip Code Field: When completing the zip code, it is critical to select the corresponding city and state from the drop-down menu that appears. If you do not select from the drop-down, the fields will gray out, preventing completion.
  • Specialty Field: Please start to type in your state licensure specialty, such as, social worker, professional counselor, nursing etc and then wait for the drop down and select the specialty. **Please DO NOT select Behavioral/Mental Health as this will not allow you to populate the title.**

If you are an RN Only or an Associate level counselor, we do not contract or credential you. PLEASE DO NOT PROCEED.

Network Closures

Oregon and Clark County Washington

For Complementary and Alternative Medicine (Chiropractors, Naturopaths, Massage Therapists and Acupuncturists) providers in Oregon and Clark County Washington, please contact Axis Healthcare for credentialing and contracting information by email [email protected] or by phone (503) 245-4100.

Please Note:

FCHN does not contract/credential in the state of . Contact Provider Relations at [email protected] for more information

Primary Location

Zip code must be 5 digits long. Please wait for the City and State to display, and select the correct option. Do not go past the zip code field until you have selected a City/State.

A Hospital-based provider is a provider whose services are performed physically within, connected to a hospital, or on a hospital campus, and are legally associated with a hospital. Please contact [email protected] to learn how to add a Hospital-Based location to your record.
Credentialing Office

Zip code must be 5 digits long. Please wait for the City and State to display, and select the correct option. Do not go past the zip code field until you have selected a City/State.