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Get PA DPW Provider Enrollment Base Application 2011

E scanned - please do NOT staple. Note: Out-of-State providers must submit proof of participation in your State’s Medicaid Program. 1. Enter the complete name of Medical Supplier. 2a. Check the appropriate boxes for the action(s) you request. 2b. If you are reactivating a provider number, indicate the PROMISe™ 13 digit provider number you wish to have reactivated and complete the application as an initial enrollment. 2c. If this is a name change, indicate the old name and the new nam.

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