How to Download a PDF Provider Enrollment Package

You can enroll as an individual or group provider, or as a Trading Partner, by mail after downloading a provider enrollment package online. Depending upon your security settings, you may also have the option to enroll a Canadian provider. You must have Adobe Acrobat Reader software installed in order to view and print the document.

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. Select which provider application package you wish to download.

4. If you select Individual or Group, you must select a Provider Type.

   Links for the appropriate forms are displayed at the bottom of the page. Different forms are displayed depending on which type of enrollment package you select.

5. Click the link for the form(s) you wish to download.

6. Download the documents.

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

7. Complete the documents, being sure to include all required information (an * asterisk indicates required fields).
8. Mail the provider enrollment package and any other necessary documentation to the address provided.

See Also

Version as of 6/30/2015.