Common Contracts
1 similar Provider Enrollment/Re-Enrollment Application and Agreement contracts
Provider Enrollment/Re-enrollment Application and AgreementProvider Enrollment/Re-Enrollment Application and Agreement • May 24th, 2013
The Department of Social Services (DSS) appreciates your interest in participating in the Connecticut Medical Assistance Program. The following types of providers are permitted to use this paper application form. If you are not a provider of the following types, you are required to enroll or re-enroll via the Web Portal at www.ctdssmap.com € Provider € Provider Enrollment or Provider Re-Enrollment. If you are not a provider of one of the following types and you submit a paper application, that application will be returned to you without further processing, thus delaying your enrollment/re-enrollment. If you are unable to submit your application via the Web portal, you may submit a paper application to HP with a letter that requests an exception to this requirement with details of the reason for this request.
