DC Home Mayor DC Guide Residents Business Visitors DC Government Kids
  • User ID:
  • Password:
HOME
WEB REGISTRATION
PROVIDER
RECIPIENT
VISIT
REPORT FRAUD AND ABUSE
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.

Signatures

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