Apply to Join the MediGold Network

To reduce any delays in the process, please make sure that all information (including your email address) is correct before submitting. With questions completing this form, please call Provider Services at 800-991-9907 (TTY711)

If this physician is already part of an existing contract with MediGold, please check this box.

If you have additional office locations, please fax to 614-546-3144.




Updated 01/2020