Adding A New Provider To An Existing Group

A new Provider should complete the Medicaid Provider Application Packet below in addition to the following information listed below:

1. Medicaid Provider Application  and Instructions
2. A copy of the individual’s NPI letter from CMS that contains the NPI and taxonomy numbers.
3. A copy of the individual’s current license

Please note: Original signatures are required of all members and the group administrator on all forms. Stamped signatures will not be accepted.  Forms must be mailed to the address in the instructions.  Faxed and/or emailed applications will not be accepted.