Group Provider Application

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List of Required Documents:

·         W-9


This form should about 10 minutes to complete.


The submit button is a Review & Submit button, which provides you with opportunity to review and double-check the accuracy of your entries (and make changes, if necessary).  After you hit submit, you will be redirected to a page explaining what to expect next.  Additionally, you will receive a confirmation email with a Reference ID and other information for you to keep while Lucet reviews the application.



To save your progress and complete this form later, use the checkbox at the upper right portion of this Form.  Enter an email address and set a password and then the system will send you a link to use to log in and continue where you left off. 

So let's start by ascertaining what regional network your Provider Group would like to join...

Not Eligible for Online Application
Please apply to the network through your local Blue Cross and Blue Shield. Lucet does not manage the provider contracts and credentialing for this Blue Plan. 
Kansas City Regional Check

Missouri Counties:
Andrew, Atchison, Bates, Benton, Buchanan, Caldwell, Carroll, Cass, Clay, Clinton, Davies, Dekalb, Gentry, Grundy, Harrison, Henry, Hold, Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Platte, Ray, Saint Clair, Saline, Vernon, Worth

Kansas Counties:
Johnson; Wyandotte

Alabama Presence? 

Arkansas Presence? 

Thank you for your interest inapplying to the Lucet network.  Unfortunately, you do not meet our geographical requirements.

Tell Me About Your Provider Group.
Please see note about Legal Entity versus DBA trade names, above.
Please note the difference between a Legal Name and a DBA (or Trade Name).

Your organization's Legal Name is the official name which has been registered with the IRS.  It is entered on Line 1 of the W-9.  DBA (standing for Doing Business As) or your trade name is how people refer to your organization in everyday speech.  It is entered on Line 2 of the W-9.

Here's a useful example from real life.  In corporate documents, Starbucks' Legal Name is Starbucks Corporation. Whereas its DBA or trade name is simply Starbucks —the name it uses on its advertising and website,and how it is generally known.
Please see note about Legal Entity versus DBA trade names, above.
Enter numbers only, no dashes
About You The Group Liaison Filling Out this Form

The Group Liason is the person whom the applicant Provider Group designates as the primary individual who will manage and administer the application and maintain the list of updated Group Provider Members.  

The Liaison has the authority to represent the Group in any decisions that may be required. If the liaison changes, the Group must provide Lucet written notification indicating the person who is the new liaison. 

A Benefit For Your Group...

As an in-network provider, you will have access to our free direct scheduling platform. This software will allow you to open your appointment availability to Lucet members seeking behavioral health services. The program offers many benefits to providers, allowing you to optimize your day and track availability and patient progress. 

Thank you for your interest in joining Lucet’s provider network. While we are not currently active in your state, that is subject to change. If you’d like to stay in touch, fill out the attached form for updates. A Lucet team member will reach out if we become active in your location.
User Guidance:  Crafting a Practice Bundle with this Form

About Address Validation
This form uses Address Validation to ensure data quality for this important piece of information.  Start by typing the Street Address into the Billing Street Address field below, and before long (8 - 10 characters) you should see your full Street Address appear  -- possible as a choice item among many in the drop-down. (The more you type, the shorter the list becomes.)

After selecting the correct address from the choices, you'll find that the City, State and Zip Code fields for that address block populate automatically.  

Do remember to add a Suite #, if appropriate to the Address Line 2 Field for the address block.

The validation system is robust. That said, on occasion applicants report finding that they cannot find their address.  If this happens you will be prevented from using the validated address block.  At the bottom of the page there is a long text field Miscellaneous Notes. Enter and label your addresses there, and Lucet staff will take care of overriding the system.
Group Billing Address
Group Practice Location(s)
Group Practice Location 
Group Liaison Certification & Attestation to Accuracy& Truthfulness

By checking this box I, the Group Liaison so specified in the fields above, hereby certify that I have reviewed all the information entered in this form and attest that it is true and accurate. I understand that any provider data subsequently found to be untrue and/or materially incorrect can result in my termination from the Lucet network.