This form should
about 10 minutes to complete.
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.
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
So let's start by ascertaining what regional network your Provider Group would like to join...