Enrollment Checklists
Some provider types may not have an enrollment checklist. For information on enrolling, please refer to the Enrollment Information Booklet.
| Provider Type | Title | Updated Date |
|---|---|---|
| 14 | Behavioral Health Outpatient Treatment | n/a |
| 17 | Special Clinics | n/a |
| 20 (Spec. 699) | Children’s Cancer and Rare Diseases Clinic | 06/20/25 |
| 28 | Pharmacy | 07/08/25 |
| 33 | Durable Medical Equipment, Prosthetics, Orthotics and Disposable Medical Supplies (DMEPOS) | 07/08/25 |
| 43 | Laboratory, Pathology/Clinical | 07/08/25 |
| 54 | Targeted Case Management | 07/08/25 |
| 63 | Psychiatric Residential Treatment Facility (PRTF) | Psychiatric Residential Treatment Facility (PRTF) Attestation Form | 07/08/25 |
| 85 | Applied Behavior Analysis (ABA) | 07/08/25 |
| 87 | Crisis Services | n/a |
| 91 | Pharmacist | 07/08/25 |
| 93 | Substance Use Treatment | n/a |