Common Contracts
1 similar Provider Enrollment/Re-Enrollment Application and Agreement contracts
Connecticut Department of Social Services Provider Enrollment/Re-enrollment Application and AgreementProvider Enrollment/Re-Enrollment Application and Agreement • March 4th, 2022
The Department of Social Services (DSS) appreciates your interest in participating in the Connecticut Medical Assistance Program. All applications must be submitted electronically via the Web portal at www.ctdssmap.com. If you are unable to submit your application via the Web portal and wish to request an exception from DSS to allow a paper application to be submitted, please complete the following application. When mailing the completed application to Gainwell Technologies, please enclose a signed statement on your letterhead explaining the hardship preventing you from submitting the application online. If DSS approves your request, the application will be processed. If DSS denies the request to submit the application on paper, you will be contacted, and the application must then be submitted via the Web. To enroll/re-enroll via the Web Portal, go to www.ctdssmap.com 🡪 Provider 🡪 Provider Enrollment or Provider Re-Enrollment.
