Provider Enrollment Documents
The table below contains links to applicable provider enrollment forms for each provider type.
 
Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs, Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website. Paper applications will continue to be accepted for processing.

*All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them. 

PROMISe™ Provider Type
(Code and Description)
Enrollment Documents
 
01 - Inpatient Facility:

*Acute Care Hospital 
 
*Emergency Room
 
*Short Procedure Unit Requirements
 
*Inpatient Psychiatric
 
* Inpatient Drug & Alcohol Rehabilitation
 
*Inpatient Medical Rehabilitation
 
*JCAHO Certified RTF (Residential Treatment Facility)
 
 
 
 
 
 
 
02 - Ambulatory Surgical Center
03 - Extended Care Facility
04 - Rehabilitation Facility
05 - Home Health Agency
06 - Hospice
07 - Capitation

08 - Clinic 

* Federally Qualified Health Center

* Rural Health Clinic

* Non-FQHC/RHC Clinics

 
 
 
09 - Certified Registered Nurse Practitioner (CRNP)
10 - Midlevel Practitioner *Midlevel Practitioner Requirements

11 - Mental Health/Substance Abuse Services Provider

*Mental Health/Substance Abuse Providers

*Social Worker

*Social Worker Requirements 

12 - School Corporation
14 - Podiatrist
15 - Chiropractor
16 - Nurse
17 - Therapist
18 - Optometrist
19 - Psychologist
20 - Audiologist
21 - Case Manager
23 - Nutritionist
24 - Pharmacy
25 - Durable Medical Equipment/Medical Supplies
26 - Transportation Provider
27 - Dentist
28 - Laboratory
29 - Mobile X-ray Clinic
30 - Renal Dialysis Clinic
31 - Physician/Physician Group
32 - Certified Registered Nurse Anesthetist (CRNA)
33 - Certified Nurse Midwife
35 - Public School
37 - Tobacco Cessation Provider
40 - Medically Fragile Foster Care Provider* Medically Fragile Foster Care Provider Requirements
43 - Homemaker Agency* Homemaker Agency Requirements
47 - Birthing Center* Birthing Center Requirements
51 - Home and Community Habilitation
51 - CSPPPD Provider
Online Application
*Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet
52 - Community Residential Rehabilitation* Requirements / Additional Information / Forms
53 - Employment Competitive
54 - Intermediate Service Organization

55 - Vendor

56 - Residential Treatment Facility (RTF) - Non-JCAHO Certified* Requirements / Additional Information / Forms
58 - Communication Services
59 - OLTL Programs
66 - Funeral Director