Provider Enrollment Checklists and Signature Requirements

Individual Checklists

• Behavioral Health
• Ancillary Providers – Includes speech, physical, occupational and audiology therapists.
• Dental Providers
• Mid-Level Providers – Includes nurse practitioners, physician assistants, certified registered nurse anesthetists, certified nurse midwives, clinical nurse specialists and hospitalists.
• Pharmacists
• Physicians and Chiropractors

Group Practice Checklists

• Ambulance
• Dental
• Durable Medical Equipment
• Home Health, Hospice, Dialysis, Hospitals, Skilled Nursing and Ambulatory Surgery Centers
• Pharmacy
• Physician Office

Other Checklists

• Changes or Updates
• In State, Out-of-Network
• Out-of-State, Out-of-Network
• Satellite Locations

Signature Requirements

• Signature Requirements