Provider Enrollment Application Instructions
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 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.
Also Required (See Credentialing Requirements Checklist for provider type specific requirements):
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