North Dakota Medicaid
Provider Enrollment - Paper Forms
Please complete, sign, and submit all of the forms below.
In addition to the online enrollment, you will need to submit the following forms:
- Medicaid Program Provider Agreement (SFN 615)
- Ownership/Controlling Interest and Conviction Information (SFN 1168)
- Any applicable licensure:
- Medical Providers - 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 hospital, we would require a copy of your current hospital facility license.
- Pharmacy Providers - Both a State of North Dakota license and DEA license are required and copy sent with application. A North Dakota Pharmacy license is required to serve North Dakota citizens.
- Non-Emergency Transportation Providers - Requires a current driver's license and proof of liability insurance.
- An additional form is required for:
- Rates – Rates must be included for all UB-04 applications with the exception of those billing hospital services.
- Out-of-State (OOS) Providers - Out-of-State Enrollment Clarification Form (SFN 509)