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NOTE: Individual Substance Use Disorder providers including physicians, nurse practitioners, and psychologists-(PhD or MA) must complete the Standard Provider Application.
Standard Provider Application
Rendering Provider Application
Paper Rendering Provider Application
Providers must contact Provider Services prior to the effective date of the Change of Ownership (CHOW) or change in EIN. Advance notice is crucial for claim submissions regarding both the termination of the old provider number and assignment of the new provider number.
Answers to frequently asked questions about out of state provider enrollment and claims submission.
Mail All Enrollment Documents to: