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  • 18,219 complaints received
  • 5,038 Field Investigations
  • $17,367,942 saved
  • June 1, 2013 - May 31, 2014

    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
    *Hospital Clinic
    * Emergency Room Arrangement 1 and 2
     
    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
    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
    * 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