Local Education Agency (LEA) Providers

Local Education Agencies (school departments) must sign an Interagency Agreement with the Executive Office of Health and Human Services in order to become a Medicaid Provider.

Please complete the following information:

  1. Local Education Agency (LEA) Provider Form and Instructions
  2. Include a copy of the individual’s NPI letter from CMS that contains the NPI and taxonomy numbers.

Additional Forms

Authorization for Direct Deposit (Mandatory)

Provider Change of Information Form