Enrollment Information

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 Erollment 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.

Additional Enrollment Forms - PROMISe™ Service Location Change Request and Instructions

If you moved - Drs. Office, Home Health Agency or Hospice click here

Individual Assignment of Fees Request click here

PLEASE NOTE: Click here for the enhanced ownership or controlling interest form. It is mandatory for most provider applications. Please check your requirements page to see if it applies to you.

PROMISe™ Provider Type (Code and Description)	Enrollment Documents
01 - Inpatient Facility: * General Hospital Acute Care	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
01 - Inpatient Facility: * Inpatient Psychiatric Unit * Inpatient Psychiatric Hospital * Out-of-State Psychiatric Hospital	* Enrollment Application / Provider Agreement *Requirements / Additional Information / Forms
01 - Inpatient Facility: * 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	Enrollment Application / Provider Agreement Requirements / Additional Information / Forms
01 - Inpatient Facility: * Residential Treatment Facility (RTF) - JCAHO	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
01 - Inpatient Facility: * Emergency Room Arrangement 1 and 2	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
01 - Inpatient Facility: * Hospital Clinic	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
02 - Ambulatory Surgical Center	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
03 - Extended Care Facility	* Enrollment Application * Requirements Forms Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility	Enrollment Application / Provider Agreement Requirements / Additional Information / Forms
05 - Home Health Agency	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
06 - Hospice	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
07 - Capitation	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
08 - Clinic	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * FQHC Provider Agreement
09 - Certified Registered Nurse Practitioner (CRNP)	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
11 - Mental Health/Substance Abuse Services Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
12 - School Corporation	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
14 - Podiatrist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
15 - Chiropractor	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
16 - Nurse	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
17 - Therapist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
18 - Optometrist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
19 - Psychologist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
20 - Audiologist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
21 - Case Manager	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
23 - Nutritionist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
24 - Pharmacy	* Enrollment Application / Provider Agreement / Requirements / Additional Information / Forms
25 - Durable Medical Equipment/Medical Supplies	* Enrollment Application / Provider Agreement / Requirements / Additional Information / Forms
26 - Transportation Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
27 - Dentist	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
28 - Laboratory	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
29 - Mobile X-ray Clinic	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
30 - Renal Dialysis Clinic	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
31 - Physician/Physician Group	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements * Access Plus Provider Agreement * Telehealth Maternal-Fetal Specialist
32 - Certified Registered Nurse Anesthetist (CRNA)	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
33 - Certified Nurse Midwife	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Group Enrollment Application and Requirements
35 - Public School	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
36 - Personal Care Services Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
37 - Tobacco Cessation Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
40 - Medically Fragile Foster Care Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
43 - Homemaker Agency	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
47 - Birthing Center	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
51 - Home and Community Habilitation	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
51 - CSPPPD Provider	Enrollment Application / Provider Agreement Requirements / Additional Information / Forms * Enrollment Checklist * Region Breakdown * Regional Rate Sheet
52 - Community Residential Rehabilitation	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
53 - Employment Competitive	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
54 - Intermediate Service Organization	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
55 - Vendor * Aging Waiver	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Aging Waiver Provider Enrollment Application / Provider Agreement * Requirements / Additional Information * Enrollment Checklist * Region Breakdown * Regional Rate Sheet
56 - Residential Treatment Facility (RTF) - Non-JCAHO Certified	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
58 - Interpreter	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms
59 - Attendant Care Provider	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms * Enrollment Checklist * Region Breakdown * Regional Rate Sheet
66 - Funeral Director	* Enrollment Application / Provider Agreement * Requirements / Additional Information / Forms

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