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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)
*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

02 - Ambulatory Surgical Center Online Application
ASC Requirements
03 - Extended Care Facility Online Application
Requirements
Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility Online Application
Rehabilitation Facility Requirements
05 - Home Health Agency Online Application
* Home Health Agency Requirements
06 - Hospice Online Application
Hospice Requirements
07 - Capitation Enrollment Application / Provider Agreement
Capitation Requirements

08 - Clinic 

* Federally Qualified Health Center
* Rural Health Clinic
* Non-FQHC/RHC Clinics

*Training for FQHC

Online Application

*FQHC Requirements / Additional Information 
*RHC Requirements / Additional Information  
*Non-FQHC/RHC Clinic Requirements / Additional Information

*Training for FQHC: Slide Deck | Video | FAQ

09 - Certified Registered Nurse Practitioner (CRNP) Online Application
CRNP Requirements

10 - Midlevel Practitioner

*Pharmacist Training

Online Application 
*Midlevel Practitioner Requirements

*Pharmacist Training: Slide Deck | Video

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

13 - Non-Traditional Provider

*Doulas Training 

Online Application
*Non-Traditional Provider Requirements

*Doulas Training: Slide Deck | Video | Follow-Up Questions

14 - Podiatrist Online Application
Podiatrist Requirements
15 - Chiropractor Online Application
Chiropractor Requirements
16 - Nurse Online Application
Nurse Requirements
17 - Therapist Online Application
Therapist Requirements
18 - Optometrist Online Application
Optometrist Requirements
19 - Psychologist Online Application
*Psychologist Requirements
20 - Audiologist Online Application
Audiologist Requirements
21 - Case Manager Online Application
*Case Manager Requirements
23 - Nutritionist Online Application
Nutritionist Requirements
24 - Pharmacy

Online Application 
*Pharmacy Requirements 

25 - Durable Medical Equipment/Medical Supplies

Online Application 
*DME Requirements

26 - Transportation Provider Online Application
Transportation Requirements
27 - Dentist Online Application
Dentist Requirements
28 - Laboratory Online Application
Laboratory Requirements
29 - Mobile X-ray Clinic Online Application
Mobile X-ray Clinic Requirements
30 - Renal Dialysis Clinic Online 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 Midwife Online Application
Certified Nurse Midwife Requirements
35 - Public School Online Application
Enrollment Application / Provider Agreement
Public School Requirements
37 - Tobacco Cessation Provider Online 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 Habilitation Online Application
Requirements / Additional Information / Forms
52 - Community Residential Rehabilitation

Online Application 
Requirements / Additional Information / Forms

53 - Employment Competitive Online Application
Requirements / Additional Information / Forms
54 - Intermediate Service Organization Online Application
Requirements / Additional Information / Forms
55 - Vendor Online Application
Requirements / Additional Information / Forms
56 - Residential Treatment Facility (RTF) — 
Non-JCAHO Certified

Online Application 
Requirements / Additional Information / Forms

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