Get Promise Provider Enrollment Base Application

The PROMISe PROVIDER ENROLLMENT BASE APPLICATION is a key document for healthcare providers seeking to enroll in Pennsylvania's Medical Assistance Program. This guide provides a comprehensive step-by-step approach to assist users in completing the application accurately and efficiently.

Follow the steps to fill out the application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the complete name of the Pharmacy/Medical Supplier in the designated field.
3. Indicate whether this is your initial enrollment by selecting the appropriate box, or check if this is a revalidation.
4. If reactivating a provider number, specify the PROMISe™ 13-digit provider number to be reactivated and complete the application as initial enrollment.
5. Enter your National Provider Identifier (NPI) Number along with any taxonomy codes (include additional sheets if necessary).
6. Fill in the requested effective date for your enrollment action.
7. Provide your provider type number and a description, for example, 'provider type 31, Physician'.
8. If applicable, enter your specialty name(s) and code number(s), following the requirements for your provider type.
9. Input your Tax Identification Number (TIN) and attach a copy of TIN documentation generated by the IRS.
10. Type your legal name as filed with the IRS and as it appears on IRS documents.
11. Indicate whether you participate with any Pennsylvania Medicaid Managed Care Organizations (MCOs) and provide their names.
12. If applicable, indicate if you are operating under a fictitious business name and include the necessary documentation.
13. Complete the IRS address and ensure correct contact information is provided.
14. Select your business type by checking one applicable box.
15. If applicable, enter your license number, issuing state, issue date, and expiration date, including a copy of your license.
16. Provide your Drug Enforcement Agency (DEA) Number, if applicable, with a copy of the DEA certificate.
17. Enter your CMS certification number, if applicable.
18. Input a valid service location address (physical location) and include all relevant contact information.
19. Review the confidential information section and answer all questions; include any required explanations as necessary.
20. Sign the application with original signature, print your name, title, and date.
21. If you need to add additional addresses, complete the corresponding section without adding a new service location.
22. Once completed, review the checklist provided in the application, save your changes, and proceed to download, print, or share the final document as necessary.

Complete your PROMISe PROVIDER ENROLLMENT BASE APPLICATION online today to ensure timely processing of your enrollment.