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​CHIP Provider Enrollment Information

The Department of Human Services (Department) is implementing the Affordable Care Act (ACA) Provider Screening and Enrollment provisions which require all providers who render services to CHIP enrollees to be enrolled with the Department of Human Services. To enroll, providers must complete an enrollment application appropriate for their provider type and submit all required documents. If a provider is already enrolled in the Pennsylvania Medical Assistance program, the provider does not need to enroll again in CHIP.

Criminal Background Check

The Department of Human Services has assigned certain provider types and specialties to the "high" categorical risk level. The Affordable Care Act (ACA) requires all providers deemed to be a high categorical risk level to obtain criminal background checks, which include a Federal Bureau of Investigation (FBI) criminal background check and a Pennsylvania State Police Criminal Record Check. Any person with a 5 percent or greater direct or indirect ownership interest in the high-risk provider must also submit criminal background check information. For more information, please see Medical Assistance Bulletin 99-17-03.

Please do not register through either of the below links unless you have been notified by the Department that you, or the Provider you own, are classified as a High Risk provider and must be fingerprinted. Applicants seeking Child Abuse Clearances for purposes of employment, due to working with children, for example, should NOT use the below links.

If you are an individual provider who has been placed in the "high" categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check. 

If you are the owner of a provider that has been placed in the "high" categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check. 

Please note that if the banner at the top of the screen does not read OMAP – Medical Assistance Provider Direct/Indirect Ownership Interest or OMAP – Medical Assistance Provider, your background check information will be sent to the wrong office and you will have to re-register.

Once registered, you will be assigned a registration code. Please enter that code and the date of your screening into the Electronic Provider Portal application. 

To obtain a Pennsylvania State Police Criminal Record Check, visit the Pennsylvania State Police Criminal Record Check website. The department will request the results of the State Police Criminal Record Check from the provider and any person with a 5 percent or greater ownership interest in the provider. Please retain and submit these results directly to the Department.

Enroll Electronically 

CHIP Providers are now able to enroll through the electronic provider enrollment application. The benefits of using the secure online portal are:

Enroll on Paper

The table below contains links to applicable provider enrollment forms for each provider type. Print the documents for your provider type and follow the instructions for completing the documents. Please check if the provider type has additional requirements that must be included with the application. Click here for a list of provider types and specialties for CHIP providers/CHIP Provider Crosswalk

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

For questions, please call Provider Enrollment at 1-800-537-8862 and select option 3, then option 1, option 1 and option 4.

CHIP Provider Type

(Code and Description)

Enrollment Documents
01 - Inpatient Facility

CHIP ONLY Facility/Agency Enrollment Application

**Additional requirements for Inpatient Facilities:
Acute Care Hospital
Psychiatric Hospitals and Units
Medical Rehabilitation Hospitals and Units
JCAHO Certified RTF (Residential Treatment Facility)
Hospital-Based Medical Clinic
Short Procedure Unit in a Hospital

02 - Ambulatory Surgical CenterCHIP ONLY Facility/Agency Enrollment Application
03 - Extended Care FacilityCHIP ONLY Facility/Agency Enrollment Application
04 - Rehabilitation FacilityCHIP ONLY Facility/Agency Enrollment Application
05 - Home Health AgencyCHIP ONLY Facility/Agency Enrollment Application
06 - HospiceCHIP ONLY Facility/Agency Enrollment Application
07 - CapitationCHIP ONLY Facility/Agency Enrollment Application

08 - Clinic  
Including: Federally Qualified Health Center, Rural Health Clinic, Non-FQHC/RHC Clinics

CHIP ONLY Facility/Agency Enrollment Application 
**Additional Requirements for Clinics

09 - Certified Registered Nurse Practitioner (CRNP)

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application  
** Additional requirements for CRNPs

10 - Midlevel Practitioner 
Including: Physician Assistants, Public Health Dental Hygienist, Acupuncturists
 
CHIP ONLY Individual Provider Application

11 - Mental Health/Substance Abuse Services Provider

CHIP ONLY Facility/Agency Enrollment Application  
CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
**Additional requirements for individual Mental Health Substance Abuse providers.

 14 - Podiatrist

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 

 15 - ChiropractorCHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 
 16 - NurseCHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 
 17 - TherapistCHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 
 18 - OptometristCHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 
 
19 - Psychologist

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 
20 - Audiologist

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
**Additional requirements for Audiologist
 

 21 - Case Manager

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 23 - Nutritionist

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 24 - Pharmacy

*CHIP ONLY Facility/Agency Enrollment Application
 **Additional requirements for Pharmacies 

 

 25 - Durable Medical Equipment/Medical SuppliesCHIP ONLY Facility/Agency Enrollment Application
 26 - Transportation ProviderCHIP ONLY Facility/Agency Enrollment Application
 
27 - Dentist

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application 
 **Additional requirements for Dentist/Orthodontists 

 28 - Laboratory

CHIP ONLY Facility/Agency Enrollment Application 
**Additional requirements for Laboratories

 29 - Mobile X-ray Clinic and IDTFCHIP ONLY Facility/Agency Enrollment Application
 
 30 - Renal Dialysis ClinicCHIP ONLY Facility/Agency Enrollment Application
**Additional Requirements for Renal Dialysis Clinic

 31 - Physician/Physician Group

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 
32 - Certified Registered Nurse Anesthetist (CRNA)

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 
33 - Certified Nurse Midwife

CHIP ONLY Individual Provider Application 
CHIP ONLY Group Provider Application

 37 – Tobacco CessationCHIP ONLY Facility/Agency Enrollment Application
 
 47 – Birth CenterCHIP ONLY Facility/Agency Enrollment Application