Provider Help

Contact Provider Relations

Please submit the form below to contact Provider Relations for assistance.

Please fill out the form to the best of your ability with as much information as possible. Not all fields may apply to your request.

Provider Ticket Submission Form
First Name
Last Name
Email
Phone
Provider/Agency Name
Provider Tax ID
Agency / Provider Type	SELECT AGENCY/PROVIDER TYPEBehavioral HealthDD AgencyHealthcare Agency – OtherHome CarePT/OT/STVendor – Audiology/Hearing AidsVendor – DentalVendor – DMEVendor – Nurse Advice LineVendor – PharmacyVendor – TelemedicineVendor – TransportationVendor – Vision
Region	SELECT COUNTYBronxBrooklyn / KingsManhattan / New YorkNassauQueensRocklandStaten Island / RichmondSuffolkWestchester
Category	SELECT CATEGORYBalance BillingClaim or Authorization IssueDirectory AssistanceGeneral InquiryHEDISInformation OnlyMediSked Provider InquiryMember Appointment IssueProvider Information UpdateProvider Needs Re-educationProvider Recruitment RequestSingle Case AgreementVendor Related IssueWage Parity Statements
Sub Category	SELECT SUB CATEGORYCare Manager InquiryProvider InquiryVendor InquiryOther
Subject
Description of Assistance Need
Priority	-None-HighMediumLowUrgent
Attachment	Attach files Each of your file(s) can be up to 20MB in size.You can attach as many as 5 files at a time.
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