Provider Enrollment

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Important Announcements

The system requirements and notes below are provided to assist in ensuring the best possible user-experience while working in the Provider Enrollment Portal:
- Microsoft Internet Explorer version 7.0 or later.
- Mozilla Firefox 2.0 and later.
- Screen Resolution 1024 x 768 pixels (optimal).
- Do not attempt to use the back/forward buttons in the browser. Doing so may cause you to lose your progress. Instead, use the navigation section within the application.
- Inactivity on pages may also cause you to lose your progress.
- Be aware that if a password has been created, it cannot be reset and Enrollment does not have access to the password.
- Be aware that you will only be able to save your progress one time. Once you exit and resume an application the save option is not available. The application must be completed and submitted or cancelled.

Provider Enrollment

Enrollment Application

Initiate a new electronic enrollment application.

EFT Enrollment Application

Initiate an EFT Enrollment application.

ERA Enrollment Application

Initiate an ERA Enrollment application.

Resume Enrollment

Resume an existing electronic enrollment application that has not been submitted.

Enrollment Status

Check the current status of an electronic enrollment application.

Forms Library

Provider Enrollment Forms

R4.0