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Rendering App

Rendering Application

Rendering Provider Application enrollment requires a SSN only. A rendering provider is the individual that provides services to a Medicaid client. In most instances, a rendering provider has the option to be either a direct pay entity or an indirect pay entity under only his/her SSN. If an individual has obtained an EIN to identify a business entity, both a rendering and a standard application may  need to be completed. For instance a dentist will need to enroll once as an indirect pay, or rendering provider, using his/her SSN and as a direct pay provider using the EIN to complete the Standard Provider Application for a dental clinic.

 Please find the applicable provider type and access all documentation needed in the following table.

Rendering Provider Application

 ♦ SSN only
 ♦ Must affiliate to a billing/direct
    pay entity

Electronic Fillable Rendering Application

Additional Documentation



 Certified Registered Nurse Anesthetist


 Dental Hygienist






 Nurse Practitioner


 Occupational Therapist







 Physical Therapist



 Physician Assistant




 Psychologist (PhD or MA)

How to bill for mental health services

 Registered Nurse

Supervision Form (04/14)

 Speech Therapist