Enrollment Information
In order for providers to participate with the Department of Human Services, they must first enroll.
  • To be eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate state agency.
  • Out-of-state practitioners must be licensed and currently registered by the appropriate agency in their state, and they must provide documentation that they participate in that state's Medicaid program.
  • Other providers must be approved, licensed, issued a permit, or certified by the appropriate state agency, and — if applicable — certified under Medicare.
To enroll, providers must complete an enrollment application appropriate for their Provider Type and submit all required documents necessary for that provider type.
 
Co-locating or sharing space
Providers seeking to enroll at a site that is located within another provider’s office may complete the attestation form and submit it and proposed signage to the department. Please follow the directions specified in the MA Bulletin 99-16-04. The attestation forms are attached to the MA Bulletin.
 
Criminal Background Check
The Department of Human Services has assigned certain provider types and specialties to the “high” categorical risk level. The Affordable Care Act (ACA) requires all providers deemed to be a high categorical risk level to obtain criminal background checks, which include a Federal Bureau of Investigation (FBI) criminal background check and a Pennsylvania State Police Criminal Record Check. Any person with a 5 percent or greater direct or indirect ownership interest in the high risk provider must also submit criminal background check information. For more information, please see Medical Assistance Bulletin 99-17-03.
 
If you are an individual provider who has been placed in the “high” categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check.
 
If you are the owner of a provider that has been placed in the “high” categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check.
 
Please note that if the banner at the top of the screen does not read OMAP – Medical Assistance Provider Direct/Indirect Ownership Interest or OMAP – Medical Assistance Provider, your background check information will be sent to the wrong office and you will have to re-register.
 
Once registered, you will be assigned a registration code. Please enter that code and the date of your screening into the Electronic Provider Portal application.
 
If you have not received a letter from the Department supplying you with a voucher code but you believe you are subject to the criminal background check screenings, please call the Department at 1.800.537.8862 option 3, option 1, option 1, then option 4 to speak with the Fingerprint-Based Criminal Background Check team.
 
To obtain a Pennsylvania State Police Criminal Record Check, visit the Pennsylvania State Police Criminal Record Check website. The department will request the results of the State Police Criminal Record Check from the provider and any person with a 5 percent or greater ownership interest in the provider. Please retain and submit these results directly to the Department.
 
Enroll electronically

» ELECTRONIC PROVIDER ENROLLMENT APPLICATION 

Providers are now able to enroll through the electronic provider enrollment application. The benefits of using the secure online portal are:

Enroll on paper

The table below contains links to applicable provider enrollment forms for each provider type. Print the documents for your provider type and follow the instructions for completing the documents.

View Frequently Asked Questions

All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them. 

Additional Enrollment Forms
I need to close a service location on my provider file: PROMISe™ Service Location Change Request and Instructions; Block #1
 
I need to change the mailing, payment and/or 1099 address for an existing service location on my provider file:
PROMISe™ Service Location Change Request and Instructions; Block #2

I have relocated my practice and need to update my provider file: Provider Practice Relocation Request

 
I need to assign my fees to my employer: Individual Request for Assignment of Fees
 
I need to terminate an assignment of fees: PROMISe™ Service Location Change Request and Instructions; Block #3
 

I need more information about Provider Eligibility Programs (PEPs): Provider Eligibility Program (PEP) Descriptions

 
My company has had a change of ownership *without* a change in the IRS tax number: Ownership and Control Interest Form
 
My company has had a change of ownership *WITH* a change in the IRS tax number:
Please call Melissa Fetzer at (717) 257-5217 to discuss what documents will be needed.
 
If you have any questions about completing any of the documents, please call the appropriate phone number shown on the Important Phone Numbers and Addresses page of this site.
 

 

PROMISe™ Provider Type
(Code and Description)
Enrollment Documents
01 - Inpatient Facility:

 
 
Acute Care Hospital
 
*Inpatient Psychiatric
 
* Inpatient Drug & Alcohol Rehabilitation
 
*Inpatient Medical Rehabilitation
 
*JCAHO Certified RTF (Residential Treatment Facility)
 
 
 
 
 
02 - Ambulatory Surgical Center* Enrollment Application / Provider Agreement
* ASC Requirements
03 - Extended Care Facility* Enrollment Application
* Requirements
* Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility*Enrollment Application / Provider Agreement
* Rehabilitation Facility Requirements
05 - Home Health Agency* Enrollment Application / Provider Agreement
* Home Health Agency Requirements
06 - Hospice* Enrollment Application / Provider Agreement
* Hospice Requirements
07 - Capitation* Enrollment Application / Provider Agreement
* Capitation Requirements

08 - Clinic 

* Federally Qualified Health Center

* Rural Health Clinic

* Non-FQHC/RHC Clinics
 

 

 
 
 
 
 
 
09 - Certified Registered Nurse Practitioner (CRNP)* Enrollment Application / Provider Agreement
* CRNP Requirements
* CRNP Group Application
10 - Midlevel Practitioner

11 - Mental Health/Substance Abuse Services Provider

*Mental Health/Substance Abuse Providers

*Social Worker

*Mental Health/Substance Abuse Provider Requirements

*Social Worker Requirements 

12 - School Corporation* Enrollment Application / Provider Agreement
* School Corporation Requirements
14 - Podiatrist* Enrollment Application / Provider Agreement
* Podiatrist Requirements
* Podiatrist Group Application
15 - Chiropractor* Enrollment Application / Provider Agreement
* Chiropractor Requirements
* Chiropractor Group Application
16 - Nurse* Enrollment Application / Provider Agreement
* Nurse Requirements
* Nurse Group Application
17 - Therapist* Enrollment Application / Provider Agreement
* Therapist Requirements
* Therapist Group Application
18 - Optometrist* Enrollment Application / Provider Agreement
* Optometrist Requirements
* Optometrist Group Application
19 - Psychologist* Enrollment Application / Provider Agreement
*Psychologist Requirements
* Psychologist Group Application
20 - Audiologist* Enrollment Application / Provider Agreement
* Audiologist Requirements
* Audiologist Group Application
21 - Case Manager* Enrollment Application / Provider Agreement
*Case Manager Requirements
23 - Nutritionist* Enrollment Application / Provider Agreement
* Nutritionist Requirements
*Nutritionist Group Application
24 - Pharmacy
25 - Durable Medical Equipment/Medical Supplies
26 - Transportation Provider* Enrollment Application / Provider Agreement
* Transportation Requirements
27 - Dentist* Enrollment Application / Provider Agreement
* Dentist Requirements
* Dentist Group Application
28 - Laboratory* Enrollment Application / Provider Agreement
* Laboratory Requirements
29 - Mobile X-ray Clinic* Enrollment Application / Provider Agreement
* Mobile X-ray Clinic Requirements
30 - Renal Dialysis Clinic* Enrollment Application / Provider Agreement
* Renal Dialysis Clinic Requirements
31 - Physician/Physician Group
32 - Certified Registered Nurse Anesthetist (CRNA)* Enrollment Application / Provider Agreement
* CRNA Requirements
* CRNA Group Application
33 - Certified Nurse Midwife* Enrollment Application / Provider Agreement
* Certified Nurse Midwife Requirements
* Certified Nurse Midwife Group Application
35 - Public School* Enrollment Application / Provider Agreement
* Public School Requirements
37 - Tobacco Cessation Provider* Enrollment Application / Provider Agreement
* Tobacco Cessation Provider Requirements
40 - Medically Fragile Foster Care Provider* Enrollment Application / Provider Agreement
* Medically Fragile Foster Care Provider Requirements
43 - Homemaker Agency*Enrollment Application / Provider Agreement
* Homemaker Agency Requirements
47 - Birthing Center* Enrollment Application / Provider Agreement
* Birthing Center Requirements
51 - Home and Community Habilitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
51 - CSPPPD Provider

*Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet

52 - Community Residential Rehabilitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
53 - Employment Competitive* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
54 - Intermediate Service Organization* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
55 - Vendor

 

* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet

56 - Residential Treatment Facility (RTF) - Non-JCAHO Certified* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
58 - Interpreter* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
59 - OLTL Programs

* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet 
*HCBS Provider Agreement

66 - Funeral Director* Enrollment Application / Provider Agreement
*Funeral Director Requirements