Please note that only one service location and one provider type can be enrolled per application. All attachments must be complete, legible and current. You will be notified if your application cannot be processed because it is incomplete or the information is incorrect.
All providers may need the following minimum information to complete your enrollment request:
Additional information may also be required depending on provider type such as:
Please click the “Start” button to begin the enrollment process. The application will automatically save each time you click “Continue”.
Register below to be assigned a unique enrollment tracking number. Be sure to write down your password. An email confirmation will be sent with the tracking number. If you don't submit your enrollment right away, you can use this tracking number and password to resume your enrollment application later.