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:

  • Acute Care Hospital
  • Emergency Room
  • Short Procedure Unit Requirements
  • Inpatient Psychiatric
  • Inpatient Drug & Alcohol Rehabilitation
  • Inpatient Medical Rehabilitation
  • JCAHO Certified RTF (Residential Treatment Facility)
  • Medicare Enrolled Entity

Inpatient Facility Application

Emergency Room Application

 

02


Ambulatory Surgical Center (ASC)

Ambulatory Surgical Center Application

03


Extended Care Facility

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

  • Federally Qualified Health Center
  • Rural Health Clinic
  • Non-FQHC/RHC Clinics

*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:

11

Mental Health/Substance Abuse Services Provider

  • Mental Health/Substance Abuse Providers
  • Social Worker
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
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) —
Non-JCAHO Certified

RTF/Non-JCAHO Certified Application
58

Communication Services

Communication Services Application
59

OLTL Programs

OLTL Programs Application
66

Funeral Director

Funeral Director Application