Provider Enrollment Templates

This form is used for healthcare providers in Texas to apply for enrollment in the HAP (Healthcare Access Program) network.

This document is a checklist for new healthcare providers applying for enrollment in Washington, D.C. It outlines the necessary steps and requirements.

This Form is used for enrolling health centers in Oregon and is an attachment to the OHP3104 Provider Enrollment Form.

This Form is used for hospitals in Oregon to attach additional information when enrolling as a provider under the Oregon Health Plan.

This form is used for providers who are applying for enrollment as an independent radiology provider in the state of Oregon.

This Form is used for attaching school medical information to the Provider Enrollment in Oregon.

This Form is used for requesting enrollment of a child with a provider in New York City.

This form is used for providers in Ohio to apply for enrollment in the Medical Managed Care Program, without needing to be certified.

This form is used to gather information about healthcare providers participating in the Vaccines for Children (VFC) Program in the state of Iowa. It helps ensure that eligible children have access to vaccines at no cost.

This form is used for enrolling healthcare providers in the Vaccines for Children (VFC) Program in Iowa. The VFC Program provides free vaccines to eligible children to protect against vaccine-preventable diseases.

This document is for licensed mental health technicians in North Dakota who want to enroll and attest as a provider.

This Form is used for enrolling healthcare providers in the state of Arizona. It is the official document required for providers to participate in state healthcare programs and receive reimbursement for services provided.

This document is a letter sent to providers in South Carolina to request revalidation of their enrollment. Revalidation is necessary to ensure that providers continue to meet the state's requirements for participation in healthcare programs.