About Provider Enrollment Pages

You use the following pages and their related field descriptions to add or update an individual, group, or trading partner enrollment application.

Individual Provider Enrollment Pages

• Individual Provider Enrollment (Identifying Information) Page
• Individual Provider Enrollment (Licensure/Certification) Page
  
• Individual Provider Enrollment (Provider Identifier Number) Page
  
• Individual Provider Enrollment (Service) Page
  
• Individual Provider Enrollment (Group Affiliation) Page
  
• Individual Provider Enrollment (Electronic Transaction Submission) Page
  
• Individual Provider Enrollment (Ownership) Page
  
• Individual Provider Enrollment (Exclusion/Sanction) Page
  
• Individual Provider Enrollment (Qualified Service Providers) Page
• Individual or Group Provider Enrollment (Submit Application Step 1) Page
• Individual or Group Provider Enrollment (Submit Application Step 2) Page
• Individual or Group Provider Enrollment (Submit Complete) Page

Group Provider Enrollment Pages

• Group Provider Enrollment (Demographic) Page
  
• Group Provider Enrollment (Licensure/Certification) Page
• Group Provider Enrollment (Provider Identifier Numbers) Page
  
• Group Provider Enrollment (Service) Page
  
• Group Provider Enrollment (Group Affiliation) Page
  
• Group Provider Enrollment (Electronic Transaction Submission) Page
  
• Group Provider Enrollment (Ownership) Page
  
• Group Provider Enrollment (Authorized Representatives) Page
• Group Provider Enrollment (Exclusions/Sanctions) Page
  
• Group Provider Enrollment (Qualified Service Providers) Page
• Individual or Group Provider Enrollment (Submit Application Step 1) Page
• Individual or Group Provider Enrollment (Submit Application Step 2) Page
• Individual or Group Provider Enrollment (Submit Complete) Page

Trading Partner Enrollment Pages

• Trading Partner Enrollment (Identifying Information) Page
• Trading Partner Enrollment (Transactions) Page
• Trading Partner Enrollment (Provider Affiliations) Page
• Trading Partner Enrollment (Carrier Affiliations) Page
• Trading Partner Enrollment (Submit Application Step 1) Page
  
• Trading Partner Enrollment (Submit Application Step 2) Page
• Trading Partner Enrollment (Submit Complete) Page

Other Pages

• Download Enrollment Forms Page
  
• Individual or Group Provider Enrollment (Request Enrollment Package) Page
• Application Status Response Page

See Also

How to Enroll Online as an Individual Provider

How to Enroll Online as a Group Provider

How to Enroll as a Trading Partner

How to Request a Provider Enrollment Package in the Mail

How to Download a PDF Provider Enrollment Package

Version as of 5/16/14.