Providers may call the Office of Medical Assistance Programs' (OMAP) 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.
Provider Enrollment Attachments
DHS Provider Enrollment has implemented enhancements to the Electronic Portal to streamline the enrollment process and reduce the need for additional documentation. When licenses can be verified directly from the primary licensing sources: such as DEA, CLIA, and the Department of State, we will no longer require providers to upload supporting attachments.
Nurse Licenses
Pennsylvania has joined the Nurse Licensure Compact (NLC). Effective June 27, 2025, Nurses with a valid multistate license from a NLC participating state may enroll with Pennsylvania Medical Assistance without obtaining a separate license from Pennsylvania Department of State.
Please note: When selecting your nursing license, please choose the multistate license only if you live outside of Pennsylvania and plan to practice in multiple compact states.
If Pennsylvania is your primary state, select Copy of Dept. of State Provider License.
*All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them.
Training Videos
Getting started with MA FFS Enrollment Training
Provider training for getting started with Medicaid/Medical Assistance Fee For Service Enrollment.
TranscriptHealthChoices Physical Health Training
Training for people who want to enroll in HealthChoices which is the name of Pennsylvania's Medicaid /Medical Assistance Program.
Transcript
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 | |