Contact Form | Provider | Individual & Commercial Plans

vinil.chintala@carelon.com

PE Webform

Tell us about you

Please enter all requested information in the form so we can best assist you.

All fields are required unless noted as optional.

First Name

Last Name

Job Title (Optional)

Phone Number

Business Email Address

Please enter all requested information in the form so we can understand how you are serving your members.

All fields are required unless noted as ‘Optional’.

Provider Name

Provider Type

Select Ancillary Type

Are You Managed by Carelon?

Contracted State

Service Area ZIP Code

Tax ID Number (TIN)

National Provider Identifier (NPI) (Optional)

Please explain your question or concern so we can best assist you.

All fields are required.

Reference Number

Impacted Line of Business

Medicaid

Individual and Family/Commercial

Medicare/Medicare Advantage

Check all that apply.