Letter of Interest

Presbyterian continually looks to create new partnerships that ensure members have access to needed services throughout New Mexico. We offer Medicare Advantage, Medicaid, and Commercial plans. If you are a group, facility, or an individual provider, please complete the following form to begin the contracting process. We look forward to partnering with you to keep New Mexicans healthy.

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* = indicates required fields

Products of Interest*

Note: To choose Commercial, providers must also choose a government program (Medicaid or Medicare)

Practice Details

The entity's legal name, including the name it is doing business as, must match the name on the entity's W-9 form (e.g., Healthcare123 Inc. DBA HealthcareABC).
You must supply at least one Federal Tax ID Number (use only numbers without dashes or special characters).
You must supply at least one State Professional License Number.

(e.g., pediatrics – max. age 18; internal medicine – min. age 40; geriatric – min. age 50; OB/GYN – dependent on the provider)

Contact Information for Contracting Purposes

Physical Address

Required for contracting purposes

Current Mailing Address

Billing Address

Other Practice Location

Please upload the following required documents:

If necessary, please fax remaining documents to 505-923-5440.

Attach Supporting Documentation

File sizes should not exceed 4MB.
Allowed file types: .pdf, .png, .jpg, .jpeg, .gif

Please click here to download and fill out the Ownerhip & Control Interest Disclosure Form and attach it to this form below.

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