Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs' Department of Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website. Paper applications will continue to be accepted for processing.
*All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them.
PROMISEeTM Code & Provider Type | Provider Application | Facility Requirement Documents | |
|---|---|---|---|
| 01 | Inpatient Facility:
|
| |
| 02 |
| ||
| 03 |
| Extended Care Facility Application | |
| 04 | Rehabilitation Facility | Rehabiliation Application | |
| 05 | Home Health Agency | Home Health Application | |
| 06 | Hospice | Hospice Application | |
| 07 | Capitation | Capitation Application / Provider Agreement | |
| 08 | Clinic
*Training for FQHC | Clinic Application |
*Training for FQHC: |
| 09 | Certified Registered Nurse Practitioner (CRNP) | CRNP Application | |
| 10 | Midlevel Practitioner * Pharmacist Training | Midlevel Practicioner Application |
Pharmacist Training: PHDHP Training: |
| 11 | Mental Health/Substance Abuse Services Provider
| Mental Health/Substance Abuse Services Application | |
| 12 | School Corporation | School Corporation Application | |
| 13 | Non-Traditional Provider *Doulas Training | Non-Traditional Provider Application |
*Doulas Training: |
| 14 | Podiatrist | Podiatrist Application | |
| 15 | Chiropractor | Chiropractor Application | |
| 16 | Nurse | Nurse Application | |
| 17 | Therapist | Therapist Application | |
| 18 | Optometrist | Optometrist Application | |
| 19 | Psychologist | Psycologist Application | |
| 20 | Audiologist | Audiologist Application | |
| 21 | Case Manager | Case Manager Application | |
| 23 | Nutritionist | Nutritionist Application | |
| 24 | Pharmacy | Pharmacy Application | |
| 25 | Durable Medical Equipment/Medical Supplies | Durable Medical Equipment/Medical Supplies Application | |
| 26 | Transportation Provider | Transportation Provider Application | |
| 27 | Dentist | Dentist Application |
Dentist Training:
|
| 28 | Laboratory | Labratory Application | |
| 29 | Mobile X-ray Clinic | Mobile X-Ray Clinic Application | |
| 30 | Renal Dialysis Clinic | Renal Dialysis Application | |
| 31 | Physician/Physician Group | Physician/Group Application | |
| 32 | Certified Registered Nurse Anesthetist (CRNA) | CRNA Application | |
| 33 | Certified Nurse Midwife | Certified Nurse Midwife Application | |
| 35 | Public School | Public School Application | |
| 37 | Tobacco Cessation Provider | Tobacoo Cessation Application | |
| 40 | Medically Fragile Foster Care Provider | Medically Fragile Foster Care Application | |
| 43 | Homemaker Agency | Homemaker Agency Application | |
| 47 | Birthing Center | Birthing Center Application | |
| 51 | Home and Community Habilitation | Home and Community Habilitation Application | |
| 52 | Community Residential Rehabilitation | Community Residential Rehabilitation Application | |
| 53 | Employment Competitive | Employment Competitive Application | |
| 54 | Intermediate Service Organization | Intermediate Service Organization Application | |
| 55 | Vendor | Vendor Application | |
| 56 | Residential Treatment Facility (RTF) — | RTF/Non-JCAHO Certified Application | |
| 58 | Communication Services | Communication Services Application | |
| 59 | OLTL Programs | OLTL Programs Application | |
| 66 | Funeral Director | Funeral Director Application | |