Basic Care Provider Enrollment

Be sure to sign the questionnaire (last line on the first page of the application) and the provider agreement. If the forms are not signed they will be returned for signatures. This will delay the enrollment process.

1. Provider Enrollment Questionnaire SFN 973
   • http://www.state.nd.us/eforms/Doc/sfn00973.pdf
2. W-9 - Both name and Tax ID Number must be exactly the way it is reported to the IRS
   • http://www.irs.gov/pub/irs-pdf/fw9.pdf
3. Basic Care Provider Agreement SFN 308
   • http://www.state.nd.us/eforms/Doc/sfn00308.pdf
4. License(s) – Copy of facility license is required.

 

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