How to Request a Provider Enrollment Package in the Mail

You can request to receive an Individual, Group, Canadian, or Trading Partner enrollment package by mail.

Optionally, you can:

• Cancel your entries. To close the page or panel without saving your changes, click Cancel.
• Reset your entries. To clear the fields and remain on the page or panel, click Reset.

To request a provider enrollment package to be mailed

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 Request a Provider Enrollment Package in the Mail.

   The Request Enrollment Package page is displayed.

3. Select the Application Type and complete the requested information on the Request Enrollment Package page. Include all required information.
4. Verify that all information is correct.

5. Click Submit.

   A confirmation page is displayed, and an enrollment package will be sent to you within a few business days.

6. Optionally, to go back to the Provider Enrollment page, click Return to Provider Enrollment.

See Also

Version as of 6/30/2015.