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.
Please refer to Appendix A-Required Documents Check List for the complete list of required documents for your provider type.
Thank you for your interest in supporting the DC Medicaid Program.If you have any questions, please contact Conduent at 202-906-8318 or 1-866-752-9231