How to Download a PDF Provider Enrollment Package

You can enroll as an individual or group provider by mail after downloading a provider enrollment package online. You must have Adobe Acrobat Reader software installed in order to view and print the document.

Optionally, you can:

• Download enrollment instructions.
• Download provider enrollment FAQs.

To download a provider enrollment package

1. Do one of the following:

   • On the Provider menu, click Enrollment.
   • On the Quick Links pod on the public Home page, click Provider Enrollment

   The Provider Enrollment page is displayed.

2. In the Become a Provider panel, click Download a PDF Provider Enrollment Package.

   The Download Enrollment Forms page is displayed.

3. Click the appropriate application package through which you want to become a provider.

   Note: You must have Adobe Acrobat Reader software installed in order to view and print the documents.

4. Print the documents.

5. Complete the documents, being sure to include all required information.

6. Mail the provider enrollment package and any other necessary documentation to the address provided.

See Also

Download Enrollment Forms Page

How to Enroll Online or By Mail

How to Request a Provider Enrollment Package in the Mail

What Is Provider Enrollment?

About Provider Tasks

Version as of 5/16/14.