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 |