Provider Enrollment Application

Overview -  Providers may submit enrollment applications via the Web Portal as an alternative to mailing in a paper application.  The pages available on the Web Portal closely mirror the those in the paper application.

Provider Enrollment Application:  Web Page Image

Figure 74: Provider Enrollment Application Web Page Image

Provider Enrollment Application:  Web Page Details

1. On the initial page, the provider may choose to:

2. Create a new application by entering their email address and clicking 'Create.'

3. Recall a previously started application that was unfinished by entering the reference number of that application and clicking 'Recall.'

4. Receive their reference number in an email if they have forgotten it by entering their email address and clicking 'Submit.'