NEW PROVIDERS New providers are required to complete an Application form to enroll as a provider in the Medicaid Fee-For-Service (FFS) Program.
Medicaid Provider Application/Change Request Form (DHS 1139) DHS 1139 Form Instructions - New Providers Psychiatry/Psychology Credentialling Atachment Form (DHS 1139A) DHS 1139A Form Instructions Non-Emergency Ground Transportation - Taxi Cabs Attachment Form (DHS 1139B) DHS 1139B Form Instructions Home Health Services Attachment Form (DHS 1139C) DHS 1139C Form Instructions Acute Hospital Attachment Form (DHS 1139D) DHS 1139D Form Instructions Nursing Facility Attachment Form (DHS 1139E) DHS 1139E Form Instructions Intermediate Care Facility For The Mentally Retarded (ICF-MR) Attachment Form (DHS 1139F) DHS 1139F Form Instructions Early and Periodic Screening, Diagnosis And Treatment Medically Fragile Case Management Provider Attchment Form (DHS 1139G) DHS 1139G Form Instructions Early And Periodic Screening, Diagnosis And Treatment (EPSDT) Skilled Nursing And Personal Care Provider Attachment (DHS 1139H) DHS 1139H Form Instructions
ESTABLISHED PROVIDERS Established providers are required to complete a status change request to make any changes such as adding/terminating services locations, tax identification number, etc., to your Medicaid FFS Program provider information.
Medicaid Provider Application/Change Request Form (DHS 1139) DHS 1139 Form Instructions - Existing Providers
