Welcome to the Online Provider Enrollment Process

Please complete each step in the enrollment process. When you have completed all steps of the application, "Submit" and "Confirm" the application for further processing.

As a condition for entering into or renewing a provider agreement all applicants must complete an application. A true, accurate and complete disclosure of all requested information is required by the Federal and State regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State regulations to update the information submitted on the application.

You will need the following information to complete your enrollment request:

• National Provider Identifier
• Address Information including Zip Code + 4
• Taxonomy Codes
• Tax ID - either Employee Identification Number or Social Security Number
• License Number

Also, please look for required attachments for your application below and click the "Continue" button to start the enrollment application.