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 PDF
  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 

 

 

 

 

 

PDF All PDFs require the free Adobe Reader.

 

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