Common Contracts

Medicaid Enrollment Application and Agreement for Nonbilling Individual

Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers • May 28th, 2021 • Washington

• Contract Type
  Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers
• Filed
  May 28th, 2021
• Jurisdiction
  Washington

This form is used to enroll individuals who wish to become ordering, referring, prescribing providers, as well as individuals who wish for their nonbilling providers identifier to be identified on hospital services claims submitted to the Health Care Authority (HCA).