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North Dakota Medicaid

Provider Enrollment - Paper Forms

Please complete, sign, and submit all of the forms below.

The following are required for manual (paper) enrollment as a provider of any type with North Dakota Medicaid:

  1. Medcaid 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. Medical & Pharmacy Providers - Your National Provider Identifier must be registered with the Department of Human Services. Visit the NPI Registration System page to complete this.
  7. Out-of-State (OOS) Providers - Out of State Enrollment Clarification Form (SFN 509)

Additional Information for Transportation, Meals, & Lodging Providers

 

Back to Electronic (MMIS) Provider Enrollment

 

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