Interest Form for Behavioral Health Professionals

If you would like to receive information on becoming a behavioral health provider with Beacon Health Strategies, you may submit your request electronically by completing this form. 

 
Name:*
Licensure:*
License Number:
Tax ID:
Group Name:
Specialty:

Primary Office Address:

Street Address:*
Address (Line 2):
City:*
State:*
Zip Code:*  
Phone:*  
E-mail:*  
Contact Name:*

Central California Alliance for Health cannot guarantee that providers applying to contract with Beacon Health Strategies shall become contracted providers. Providers are subject to reviews based upon network adequacy and Beacon Health Strategies qualification standards.