nd.gov - The Official Portal for North Dakota State Government
North Dakota: Legendary. Follow the trail of legends
NDDHS logo Mother and daughter graphic
 arrowDHS Home arrowContact DHS arrowSkip Navigation

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:

  1. Medicaid Program Provider Agreement (SFN 615)
  2. Ownership/Controlling Interest and Conviction Information (SFN 1168)
  3. 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.
  4. An additional form is required for:
  5. Rates – Rates must be included for all UB-04 applications with the exception of those billing hospital services.
  6. Out-of-State (OOS) Providers - Out-of-State Enrollment Clarification Form (SFN 509)

Back to Electronic (MMIS) Provider Enrollment


Return to the top of the page Top of page   Go back to the previous page Back to previous page

 Get Adobe Acrobat Reader Tested for W3C WAI AA Accessibility Tested for W3C Well-Formed XHTML Code Tested for W3C Well Formed Cascading Style Sheet Code