New Enrollment, Reactivation, and/or Change of Ownership

Option 1 (preferred): Provider Ownership Enrollment Web Application

The process is designed to report ownership information electronically
Using the Provider Ownership Enrollment web application is secure, effective, and fast
Using the Provider Ownership Enrollment web application to report ownership data eliminates rejection of enrollment application due to improperly reported ownership data
Use the Provider Ownership Enrollment web application to download your enrollment packets
Click here to use the Provider Ownership Enrollment web application

Option 2 (not recommended): If you choose not to use the Provider Ownership Enrollment web application, then:

Click here for a list of provider enrollment packets that you may download, fill out, and submit via U.S. Mail

Enrollment Options