General Provider Application
Please complete, sign and mail all of the forms below.
- Provider Enrollment Questionnaire SFN 973
- W-9 - Both name and Tax ID Number must be exactly the way it is reported to the IRS
- Program Provider Agreement SFN 615 -- Must be Signed!!
- License – You must include a current, legible copy of the license applicable to the provider type you are enrolling as. For example, if enrolling as a physician, we would require a copy of your current professional physician license. If enrolling as a hopsital, we would require a copy of your current hospital facility license.
- Rates – Rates must be included for all UB-92 applications with the exception of those billing hospital services.
- All out-of-state providers are required to complete SFN509 form below to clarify why recipient received services at your facility.
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