Provider Enrollment/Re-Enrollment Application and Agreement Sample Contracts

Connecticut Department of Social Services Provider Enrollment/Re-enrollment Application and Agreement

Provider Enrollment/Re-Enrollment Application and Agreement • March 4th, 2022

• Contract Type
  Provider Enrollment/Re-Enrollment Application and Agreement
• Filed
  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.

Provider Enrollment/Re-enrollment Application and Agreement

Provider Enrollment/Re-Enrollment Application and Agreement • May 24th, 2013

• Contract Type
  Provider Enrollment/Re-Enrollment Application and Agreement
• Filed
  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.