In order for providers to participate with the Department of Public Welfare, they must first enroll. To be eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate State agency. Out-of-state practitioners must be licensed and currently registered by the appropriate agency in their state and they must provide documentation that they participate in that state's Medicaid program. Other providers must be approved, licensed, issued a permit or certified by the appropriate state agency, and if applicable certified under Medicare. To enroll, providers must complete a base provider enrollment form and any applicable addenda documents dependent on the provider type.
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.
If you have any questions about completing any of the documents, please call the appropriate phone number shown on the Important Phone Numbers and Addresses page of this site.
All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them.
* Inpatient Drug and Alcohol Unit * Inpatient Drug and Alcohol Rehabilitation Hospital * Medical Rehabilitation Unit * In-State Medical Rehabilitation Hospital * Out-of-State Medical Rehabilitation Hospital
