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 | 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 Corporation | Online Application
* School Corporation Requirements |
| 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 |