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Provider Enrollment Applications

 

Revalidate your existing application.

Start a new online application.

Provider Enrollment Wizard Tips
  • Facility
    • Alcohol & Drug Rehab
    • Ambulatory Surgical Center
    • Attendant Care for Independent Living
    • Behavioral Management/Psychiatric Rehabilitation Treatment Facility
    • Community Mental Health Center
    • Early Childhood Intervention
    • Federally Qualified Health Center (FQHC)
    • Head Start Facility
    • Home Health Agency
    • Hospice
    • Hospital
    • Indian Health Physician
    • Local Education Agency
    • Maternity Center
    • Positive Behavioral Support(PBS)
    • Public Health Agency
    • Rehabilitation Facility
    • Rural Health Clinic
    • Targeted Case Management I/DD
  • Standardized
    • Chiropractor
    • CRNA Services
    • Nurse Midwife
    • Nurse Practitioner
    • Physician Assistant
    • Physician/Osteopath
    • Podiatrist
    • Psychiatric Nurse Practitioner
    • Psychologist
  • Supplier
    • Ambulance Service
    • Durable Medical Equipment (DME)
    • Hearing Aid Specialist
    • Independent Laboratory
    • Independent X-Ray Service
    • Orthopedic Prosthetics
    • Pharmacy
  • HCBS
    • Autism(AU)
    • Frail Elderly(FE)
    • Intellectual Developmental Disabled(I/DD)
    • Physically Disabled(PD)
    • Targeted Case Management
    • Traumatic Brain Injury(TBI)
  • Specific application documents and all other forms are available.
  • To request an EFT form, contact Customer Service at 785-274-5990 or 1-800-933-6593.