Pharmacy Provider Enrollment Application

Includes:

• In-State and Out-of-State Pharmacy Providers Billing ND Medicaid for Pharmacy or DME claims

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

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. Program Provider Agreement SFN 1169
   • http://www.state.nd.us/eforms/Doc/sfn01169.pdf
4. License(s) – Both State Pharmacy and DEA licenses required and copy sent with application.
5. You must obtain a North Dakota Pharmacy license if you plan to continue to serve citizens of North Dakota.
6. All out-of-state providers are required to complete SFN509 form below to clarify why recipient received services at your facility.
   • http://www.state.nd.us/eforms/Doc/sfn00509.pdf

 

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