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Get Idaho Medicaid Application Form

PO Box 70082 Boise, ID 83707 Fax: 1 (877) 517-2041 Electronic Funds Transfer Agreement Form instructions are on the pages immediately following. An * indicates required fields. Current Provider Record Information* 1. Provider ID Number NPI Idaho Medicaid ID# 2. Provider s Name For individual providers, enter your name in the form of Last Name, First Name. For Group enrollment or Facility/Agency/Organization enrollment, provide the name of the organization. Last Name: First Name: Organi.

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