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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)

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

02 - Ambulatory Surgical CenterOnline Application
ASC Requirements
03 - Extended Care FacilityOnline Application
Requirements
Special Provider Agreement for Change of Ownerships
04 - Rehabilitation FacilityOnline Application
Rehabilitation Facility Requirements
05 - Home Health AgencyOnline Application
* Home Health Agency Requirements
06 - HospiceOnline Application
Hospice Requirements
07 - CapitationEnrollment Application / Provider Agreement
Capitation Requirements

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
10 - Midlevel Practitioner

Online Application 
*Midlevel Practitioner Requirements

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 CorporationOnline Application
School Corporation Requirements
14 - PodiatristOnline Application
Podiatrist Requirements
15 - ChiropractorOnline Application
Chiropractor Requirements
16 - NurseOnline Application
Nurse Requirements
17 - TherapistOnline Application
Therapist Requirements
18 - OptometristOnline Application
Optometrist Requirements
19 - PsychologistOnline Application
*Psychologist Requirements
20 - AudiologistOnline Application
Audiologist Requirements
21 - Case ManagerOnline Application
*Case Manager Requirements
23 - NutritionistOnline Application
Nutritionist Requirements
24 - Pharmacy

Online Application 
*Pharmacy Requirements 

25 - Durable Medical Equipment/Medical Supplies

Online Application 
*DME Requirements

26 - Transportation ProviderOnline Application
Transportation Requirements
27 - DentistOnline Application
Dentist Requirements
28 - LaboratoryOnline Application
Laboratory Requirements
29 - Mobile X-ray ClinicOnline Application
Mobile X-ray Clinic Requirements
30 - Renal Dialysis ClinicOnline Application
Renal Dialysis Clinic Requirements
31 - Physician/Physician Group

Online Application 
Physician Requirements 
Telehealth Maternal-Fetal Specialist

32 - Certified Registered Nurse Anesthetist (CRNA)Online Application
CRNA Requirements
33 - Certified Nurse MidwifeOnline Application
Certified Nurse Midwife Requirements
35 - Public SchoolOnline Application
Enrollment Application / Provider Agreement
Public School Requirements
37 - Tobacco Cessation ProviderOnline Application
Tobacco Cessation Provider Requirements
40 - Medically Fragile Foster Care Provider

Online Application 
Medically Fragile Foster Care Provider Requirements

43 - Homemaker Agency

Online Application 
Homemaker Agency Requirements

47 - Birthing Center

Online Application 
Birthing Center Requirements

51 - Home and Community HabilitationOnline Application
Requirements / Additional Information / Forms
52 - Community Residential Rehabilitation

Online Application 
Requirements / Additional Information / Forms

53 - Employment CompetitiveOnline Application
Requirements / Additional Information / Forms
54 - Intermediate Service OrganizationOnline Application
Requirements / Additional Information / Forms
55 - VendorOnline Application
Requirements / Additional Information / Forms
56 - Residential Treatment Facility (RTF) — 
Non-JCAHO Certified

Online Application 
Requirements / Additional Information / Forms

58 - Communication ServicesOnline Application
Requirements / Additional Information / Forms
59 - OLTL ProgramsOnline Application
Requirements / Additional Information / Forms
Enrollment Checklist
Region Breakdown
Regional Rate Sheet 
*HCBS Provider Agreement
66 - Funeral DirectorOnline Application
*Funeral Director Requirements