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)
*Medicare Enrolled Entity | Online Application
*Hospital Based/Outpatient Clinic Application
*Acute Care Hospital Requirements
*Emergency Room Application
*Short Procedure Unit Requirements
*Inpatient Psychiatric Requirements
*Inpatient Drug & Alcohol Rehab Requirements
*Inpatient Medical Rehabilitation Requirements
*JCAHO Certified RTF Requirements
*Medicare Enrolled Entity Requirements
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02 - Ambulatory Surgical Center | Online Application
* ASC Requirements
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03 - Extended Care Facility | Online Application
* Requirements
* Special Provider Agreement for Change of Ownerships
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04 - Rehabilitation Facility | Online Application
* Rehabilitation Facility Requirements
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05 - Home Health Agency | Online Application
* Home Health Agency Requirements
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| 06 - Hospice | Online Application
* Hospice Requirements
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| 07 - Capitation | * Enrollment Application / Provider Agreement
* Capitation Requirements
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08 - Clinic
* Federally Qualified Health Center
* Rural Health Clinic
* Non-FQHC/RHC Clinics | Online Application
*FQHC Requirements / Additional Information
*RHC Requirements / Additional Information
*Non-FQHC/RHC Clinic Requirements / Additional Information |
09 - Certified Registered Nurse Practitioner (CRNP) | Online Application
* CRNP Requirements
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10 - Midlevel Practitioner | Online Application
*Midlevel Practitioner Requirements
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11 - Mental Health/Substance Abuse Services Provider
*Mental Health/Substance Abuse Providers
*Social Worker | Online Application
*Mental Health/Substance Abuse Provider Requirements
*Social Worker Requirements |
12 - School Corporation | Online Application
* School Corporation Requirements
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14 - Podiatrist | Online Application
* Podiatrist Requirements
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15 - Chiropractor | Online Application
* Chiropractor Requirements
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| 16 - Nurse | Online Application
* Nurse Requirements
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| 17 - Therapist | Online Application
* Therapist Requirements
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| 18 - Optometrist | Online Application
* Optometrist Requirements
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| 19 - Psychologist | Online Application
*Psychologist Requirements
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| 20 - Audiologist | Online Application
* Audiologist Requirements
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| 21 - Case Manager | Online Application
*Case Manager Requirements
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| 23 - Nutritionist | Online Application
* Nutritionist Requirements
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| 24 - Pharmacy | Online Application
*Pharmacy Requirements |
25 - Durable Medical Equipment/Medical Supplies | Online Application
*DME Requirements
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| 26 - Transportation Provider | Online Application
* Transportation Requirements
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| 27 - Dentist | Online Application
* Dentist Requirements
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| 28 - Laboratory | Online Application
* Laboratory Requirements
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| 29 - Mobile X-ray Clinic | Online Application
* Mobile X-ray Clinic Requirements
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| 30 - Renal Dialysis Clinic | Online Application
* Renal Dialysis Clinic Requirements
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| 31 - Physician/Physician Group | Online Application
* Physician Requirements
* Telehealth Maternal-Fetal Specialist
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| 32 - Certified Registered Nurse Anesthetist (CRNA) | Online Application
* CRNA Requirements
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| 33 - Certified Nurse Midwife | Online Application
* Certified Nurse Midwife Requirements
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| 35 - Public School | Online Application
* Enrollment Application / Provider Agreement
* Public School Requirements
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| 37 - Tobacco Cessation Provider | Online Application
* Tobacco Cessation Provider Requirements
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| 40 - Medically Fragile Foster Care Provider | Online Application
* Medically Fragile Foster Care Provider Requirements
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| 43 - Homemaker Agency | Online Application
* Homemaker Agency Requirements
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| 47 - Birthing Center | Online Application
* Birthing Center Requirements
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| 51 - Home and Community Habilitation | Online Application
* Requirements / Additional Information / Forms
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| 52 - Community Residential Rehabilitation | Online Application
* Requirements / Additional Information / Forms
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| 53 - Employment Competitive | Online Application
* Requirements / Additional Information / Forms
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| 54 - Intermediate Service Organization | Online Application
* Requirements / Additional Information / Forms
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| 55 - Vendor | Online Application
* Requirements / Additional Information / Forms
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56 - Residential Treatment Facility (RTF) —
Non-JCAHO Certified | Online Application
* Requirements / Additional Information / Forms
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| 58 - Communication Services | Online Application
* Requirements / Additional Information / Forms
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59 - OLTL Programs | Online Application
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet
*HCBS Provider Agreement
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| 66 - Funeral Director | Online Application
*Funeral Director Requirements
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