• User ID:
  • Password:

Provider Enrollment Required Documentation

Provider Enrollment Application Instructions

  • Print out the Provider Enrollment Application and the Credentialing Requirements Checklist forms from the list of links given below.
  • After verifying your specific required documentation and completing the necessary forms, mail them, along with the signature page to:

    Xerox Provider Enrollment
    Post Office Box 34761
    Washington DC 20043-4761
  • Retain a copy of the completed application for your records.

This application will not be accepted if any portion has been filled out incorrectly, form(s) are not completed and/or missing.


Original signatures are required on the signature page. Copied or stamped signatures are not acceptable. Correction fluid is not permissible on any portion of this application including signature pages.

Contact a Provider Enrollment Specialist

You may contact a Provider Enrollment Specialist by calling (202) 906-8318 (inside DC metro area), or (866) 752-9231 (outside DC metro area) for any questions concerning this application.

Change of Ownership Applicants

All applicants who are indicating a change of ownership, please contact a Provider Enrollment Specialist.

PDF Files

PDF Files are used throughout the application as a file type for additional information documents. To view PDF files you will need Adobe Acrobat Reader installed on your machine. For a free download please click the Acrobat Reader icon.

Required Documentation:

Also Required (See Credentialing Requirements Checklist for provider type specific requirements):

  • Voided Check or Deposit Slip verifying the account number and routing number on the Direct Deposit Authorization Agreement
  • Copy of Current License (if applicable)
  • Copy of Federal Tax Deposit Coupon for verification of tax identification number on W-9
  • Copy of Social Security Card, Driver's License, Military ID or Notarized Statement for verification of Social Security Number on W-9
  • Copy of Medicare Certification (EOMB not acceptable)

Thank you for your interest in supporting the DC Medicaid Program.

If you have any questions, please contact Xerox at 202-906-8318 or 1-866-752-9231