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 on all forms. Stamped signatures will not be accepted.