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Jan 12, 2025

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Quick Links   Provider Services Provider Resources EDI Support Documentation FAQ ORP FAQs Pharmacy FAQs Search for Providers Provider Forms Search Pharmacy Forms Search Web Registration Reference Material DMAS Web Site ICD-10 CCC Providers - NPI FAQs HIPP Application NF Wage Survey Application Free Clinic FAQs

Provider Enrollment       Please select a form and click on the button to view the file.     Available applications Adult Day Health Care Ambulance Ambulatory Surgical Center Application Fee Submission Audiologist Baby Care Certified Professional Midwife Chiropractor Christian Science SNF Clinical Nurse Specialist - Psychiatric Only Clinical Psychologist Comprehensive Outpatient Rehab Facility (CORF) Consumer Directed Services Facilitation DME Developmental Disability Waiver Early Intervention Electronic Claims Submission Electronic Funds Transfer Emergency Air Ambulance Family Caregiver Training Federally Qualified Health Center Group Enrollment Packet Health Department Clinic Hearing Aid Home Health Agency Hospice Hospital Hospital Medical Surgery Mental Health and Mental Retarded Hospital Medical Surgery Mental Retarded Hospital Out-of-State Hospital TB ICF-MR Community Owned ICF-MR State Owned ICF-Mental Health ICF-State Independent Laboratory Intermediate Care Facility Local Education Agency Long Stay Hospital Long Stay Inpatient Hospital Nurse Practitioner Optician Optometrist Ordering, Referring or Prescribing Provider (ORP) PACE Personal Care Personal Emergency Response System Pharmacy Physician Physician Assistant Podiatrist Private Duty Nursing Private Mental Hospital(inpatient psych) Prosthetic Services Psych Residential Inpatient Facility Psychiatrist Qualified Medicare Beneficiary (QMB) Rehab Outpatient Rehabilitation Hospital Rehabilitation Hospital Out-of-State Renal Unit Respite Care Rural Health Clinic SNF-MR SNF-Mental Health SNF-State Skilled Nursing Home State Mental Hospital(Aged) State Mental Hospital(Med-Surg) State Mental Hospital(less than age 21)