Contracting Request Form for Diversity, Equity, and Inclusion (DEI) Providers
Complete the submission form in full, leaving no blank fields. We will review your information and contact you within 30 business days of your submission. Please note, this request form is for providers who provide Diversity, Equity, and Inclusion (DEI) specific care. Providers who submit a request and do not include their DEI specialty will not be responded to.
Our panel is currently open to providers who identify as or provide:
- Black/African American Centered Care
- Hispanic and Latinx Centered Care
- Indigenous/Native American Centered Care
- Asian and Pacific Islander Centered Care
- LGBTQIA+ Centered Care
- Sensory Disability Centered Care
- Intellectual and Developmental Disability Centered Care
- Veteran Centered Care
- Bilingual Care
- Culturally Specific Care
- Gender Affirming Care
All fields are required.