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North Dakota Medicaid

Individual Practitioner Application/Reactivation Form Packets

If you are enrolling in North Dakota Medicaid or reactivating your enrollment, choose the packet that applies to your provider type and specialty.

You must:

  • fill out the entire packet,
  • attach the required documents and
  • sign the signature pages for the packet to be considered complete.

 

General Individual Practitioner Packet (2.23mb pdf)

Licensed Addiction Counselor (LAC) Packet (2.19mb pdf)

Licensed Associate Professional Counselor (LAPC) Packet (2.24mb pdf)

Licensed Baccalaureate Social Worker (LBSW) Packet (2.20mb pdf)

Physical Therapist Packet (2.20mb pdf)

Registered Nurse Packet (2.27mb pdf)

 

Submit complete packets to North Dakota Medicaid - Provider Enrollment by:


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