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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

 Audiologist

 

 Certified Registered Nurse Anesthetist

 

 Dental Hygienist

 

 Dentist

 

 Nurse-Midwife

 

 Nurse Practitioner

 

 Occupational Therapist

 

 Optometrist

 

 Orthodontist

 

 Osteopath

 Physical Therapist

 

 Physician

 Physician Assistant

 

 Podiatrist

 

 Psychologist (PhD or MA)

How to bill for mental health services

 Registered Nurse

Supervision Form (04/14)

 Speech Therapist