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Providers


Provider Enrollment

Provider Enrollment is responsible for enrolling qualified providers to receive Medicaid reimbursement for services rendered to Medicaid recipients. Providers can enroll in the Florida Medicaid program online using the Enrollment Wizard or by downloading the Provider Enrollment Application via the Internet. Providers can also request the application using the address or the phone number provided below. The completed application and all applicable forms should be submitted to Provider Enrollment where they will be reviewed for accuracy. Upon completion of the enrollment process, approved providers are issued a nine (9) digit Medicaid provider number. The provider will then be able to participate in the Florida Medicaid program.

Provider Enrollment is also available to assist the provider with enrollment issues such as change of address, change of ownership, and re-enrollment issues.

Provider Enrollment can be reached at the following:

Address:
Florida Medicaid Provider Enrollment
P. O. Box 7070
Tallahassee, Florida 32314-7070

Phone:
1-800-289-7799 Option 4

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Enrollment Forms List
 
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Enrollment Forms

 
CategoryTitle
APPLICATIONSFlorida Medicaid Provider Enrollment Application
APPLICATIONSFlorida Medicaid Provider Enrollment Application - Clearinghouse Only
APPLICATIONSFlorida Medicaid Provider Enrollment Guide for Completing Application
APPLICATIONSManaged Care Treating Provider Registration Form
ELECTRONIC DATA INTERCHANGE (EDI)Electronic Data Interchange Agreement
MEDICAID PROVIDER AGREEMENTSInstitutional Medicaid Provider Agreement
MEDICAID PROVIDER AGREEMENTSNon-Institutional Provider Agreement
MISCELLANEOUS ENROLLMENT DOCUMENTSCommunity Behavioral Health Medicare and Third Party Crossover Form
MISCELLANEOUS ENROLLMENT DOCUMENTSElectronic Funds Transfer Authorization
MISCELLANEOUS ENROLLMENT DOCUMENTSFDLE Criminal History Check and Fingerprinting Exemption Request
MISCELLANEOUS ENROLLMENT DOCUMENTSGroup Membership Authorization
MISCELLANEOUS ENROLLMENT DOCUMENTSHome Medical Equipment License Exemption Form
MISCELLANEOUS ENROLLMENT DOCUMENTSMedicaid Pharmacy Point of Service Vendor Certification and Claims Submission Authorization Form
MISCELLANEOUS ENROLLMENT DOCUMENTSMedicaid Provider Surety Bond
MISCELLANEOUS ENROLLMENT DOCUMENTSNational Provider Identifier Registration Form
MISCELLANEOUS ENROLLMENT DOCUMENTSNew Location Code Request
MISCELLANEOUS ENROLLMENT DOCUMENTSNon-profit Organization Volunteer Board Member Affidavit for Exemption from Medicaid Criminal History Checks
MISCELLANEOUS ENROLLMENT DOCUMENTSPhysician Group Certificate of Ownership Form
MISCELLANEOUS ENROLLMENT DOCUMENTSPhysician Specialty Training Attestation
MISCELLANEOUS ENROLLMENT DOCUMENTSPractitioner Collaborative Agreement

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