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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. The rendering provider will affiliate with a clinic/facility that will submit claims and provide reimbursement to the individual. 

 

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 a rendering provider (using the SSN) to provide services to the client, and as a dental clinic (using the EIN) to complete the Standard Provider Application to submit claims.


 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)

Important enrollment information for behavioral health services

 Registered Nurse

Supervision Form (04/14)

 Speech Therapist