Fee For Service Provider Forms
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Electronic/Paper Transmitter Identification Number (TSN/Provider)

Security Packets For Direct System Access

Real-Time (PC-to-Host, CPU-to-CPU)
Security Packet A

Batch (FTP, Electronic Gateway(BBS))
Security Packet B

Portable X-ray Enrollment Packet

Physician Enrollment Packet

HIV Enhanced Fee Payment

Medicaid Obstetrical and Maternal Services (MOMS) Program

Preferred Physicians And Children (PPAC) Program (Physician)

Pharmacy Enrollment Packet

Electronic/Paper Transmitter Identification Number (TSN/Provider)

Out of State Pharmacy

Nurse Practitioner Enrollment Packet

Medicaid Obstetrical and Maternal Services (MOMS) Program

Preferred Physicians And Children (PPAC) Program (Nurse)

Registered Physician's Assistant Enrollment Packet

LPN/RN Nursing Enrollment Packet

Service Bureau Enrollment Packet

Electronic Transmitter Identification Number (TSN/Service Bureau)

Podiatrist Enrollment Packet

Dentist Enrollment Packet

Clinical Psychologist Enrollment Packet

Clinical Social Worker Enrollment Packet

Chiropractor Enrollment Packet

Therapist Enrollment Packet

Nurse Registry Enrollment Packet

Self Employed Optician-Optometrist Enrollment Packet

Hearing Aid Dealer Enrollment Packet

Transportation Enrollment Packet

Midwife Enrollment Packet

Medicaid Obstetrical and Maternal Services (MOMS) Program

Group Enrollment Packet

DME Enrollment Packet

Optical Establishment/Salaried Optician/Optometrist Enrollment Packet

Laboratory Enrollment Packet

Provider Maintenance Forms

Provider ID Request Form

CLIA Information

Personal Identification Number

Supervising Pharmacist Agreement

Collaborating Physician Form

Supervising Physician Certification

Application as a Specialist

Fee for Service Address Change Form

Rate Based Change of Address Form

Out-of-State Hospital Enrollment Package Request Form

Request for Participation Group

DEA Update Form

Medicare Info Update Form

Tax Update Form

Electronic Remittance Request Form

Electronic Prior Approval Request Form

Paper Remittance Sort Request Form

Electronic Funds Transfer (EFT) Enrollment Form

Pended Claim Recycle Request Form

Request to Disaffiliate/Delete an ETIN

Medically Fragile Children PDN Rate Enhancement

Trading Partner Agreement