Medicaid Preference Information
Please complete this form to indicate your enrollment preference with Grow Therapy and Medicaid.
Legal Name
*
First Name
Last Name
Email
*
This email needs to be what is associated with your Grow Therapy account. Please do not change on this form if it has been pre-populated for you. If it is different, reply to the original email.
Do you wish to enroll with Medicaid under Grow Therapy? Please note this applies to all states you are licensed in. Grow does not currently have the ability to allow providers to apply different preferences to multiple license states.
*
Yes
No
Please provide an explanation as to why you do not wish to work with Medicaid under Grow Therapy:
Submit
Should be Empty: