Florida Medicaid Phone Number For Providers – 1 Florida Medicaid Provider Enrollment Application Please write or print all information in blue or black ink: Applicant’s Name: Applicant’s Phone Number: ( ) Area Code Person of Contact: Contact Phone Number: ( ) Area code Return the entire registration application. Make a copy of the registration application for your files. Mail this application and all required documents to: ACS State Healthcare Provider Enrollment P.O. Box 7070 Tallahassee, FL Please note that the following applicants will not submit enrollment forms directly to ACS State Health. If you are an early intervention provider, home or community care provider, home health agency, school provider (eligible for an approved program), CMS, targeted case manager, or -management, transportation provider, send the application to your county Children’s Health Services Program or Health Care Agency Medicaid Provider Registration Administration 2308 Killearn Center Boulevard , Suite 200 Tallahassee, Florida Medicaid Health Systems Development Agency 2727 Mahan Drive Mail Stop 20 Your Florida Medical Services, Tallahassee’s Florida Medica Regional Children’s Office Note: Complete the Enrollment Application of -Medicaid provider see the manual, the website listed at the bottom of the page, or contact a tax agent for a complete list of required documents. If you have questions, call the ACS Provider Registry using the AHCA Form (December 2002).

3 Any person or entity wishing to receive payment for the provision of medical, hospital or outpatient services to Medicaid recipients must complete this form. For information on Medicaid provider enrollment in Florida, visit the website at the bottom of the page or the Medicaid Provider Enrollment Guide. Just use the current application form. If you are not sure if you have the most recent form, call your Medicaid tax agent. Please write and print in blue or black ink. 1. Business or Individual Name: 2. This item must be completed by the provider doing business under a business or corporate name, for example, ABC Corporation, doing business as ABC #1 Pharmacy (D/B /A). A supplier doing business under his own name should leave this section blank. Doing Business (D/B/A): 3. You must enter the street address of the place of service in this section. PO Box addresses are not accepted as physical addresses. Your application will be returned if you enter a valid postal address only. If you cannot receive mail at your address, enter your physical address first, followed by your PO Box address. If a Medicaid provider has more than one location, some providers are allowed to use the “New Location Code Application Form.” See Application page 22 for the form and the list of service providers that use the form. Pharmacy providers may send a letter requesting the activation of a durable medical device location code in lieu of a “New Location Code Application Form” on their letterhead. An updated Medicaid provider guide is available free of charge on the financial agent’s website. A hard copy of the manual will not be sent to you except as requested below. Get this important information online. Mail the Medicaid Bulletin to the address listed in Section 3. I would like a paper copy of the manual: Scope and Limitations of the Manual Indemnity Manual Physical Business Address: P. O. Box (if applicable) City/State: Zip Code: Business Address: Visit to register. For the Florida Medicaid Alert System. These automated alerts notify providers of any missing Medicaid information. 4. Business Area Telephone Number: ( ) Business Area Code Fax Number: ( ) Area Code AHCA Form (December 2002) Page 3

Florida Medicaid Phone Number For Providers

4 5. Enter your state at the address specified in point 3. Name of Residence: 6. All DME providers and pharmacies must be within 50 miles of the Florida border to register as providers in the state. Other providers located in Georgia and Alabama who routinely serve Medicaid recipients may register as state providers. An independent clinical laboratory located outside the state of Florida may register as a provider in the state if it is licensed and licensed under the Clinical Laboratory Improvement Amendments (CLIA) by the state of Florida. Are you an out of state supplier? Yes, I am an out-of-state provider No, I am an in-state provider 7. Enter the address where you would like your Medicaid payment information (remittance voucher) sent. If you leave this item blank, your remittance voucher in item 3 will be sent to your address. Mailing address for payment: City / State: Zip Code 8. Enter the name and phone number of the person who maintains your patient and financial records. the physical address of the storage location for each file type as requested below. This address cannot be a PO Box. Medical Record Holder Name: Financial Record Holder Name: Phone Number: ( ) Phone Number: ( ) Region Code Area Code Medical File Physical Address City/State: Zip Code : Financial File Physical Address City/State: Zip Code: 9. Applicant If not an individual, enter their Social Security number. Enter the Federal Employer Identification Number (FEIN) of the group applicant. These items are covered by Section 6109(a) of the Internal Revenue Code. An individual cannot enter the FEIN group of an applicant, even if that person is affiliated with the group. You must submit an IRS W9 form with your original signature or a copy of your Social Security card with this application. Social Security Number: OR FEIN: APPLICATION Page 4 AHCA Forms (December 2002)

Advocate’s Guide To The Florida Long Term Care Medicaid Waiver

5 10. Enter the appropriate two-digit code for the appropriate provider type from the list provided in the Medicaid Provider Enrollment Application Guide at the bottom of the page, or contact the representative of the tax in the Enter a single code section. apply for registration. Provider Type Code 11. Enter the appropriate two-digit code from the Occupational Code list on the website listed at the bottom of the Medicaid Provider Enrollment Application Guide or contact your tax representative. Board of Directors. can study any of the majors listed. If one is verified, you must attach a legible copy of your Board Certification, current Board eligibility, eligibility expiration date, or residency completion certificate. Enter the date of certification in your profession in the format MM/DD/SS. Enter the six-digit number assigned to you at the time of certification for the relevant trade. a. Primary Specialty Code This is a mandatory field for exempt home and community providers, physicians, dentists, therapists, and therapy providers. Consultant authorized to examine qualified consultant Certification certificate number date b. Secondary Check Qualification Code Un Board Certified Board Approved Certification Data Number Certificate If more than two qualifications, please attach an additional page. Be sure to include the same information for additional majors. 12. Enter the appropriate two-digit code for your practice type from the list provided in the Medicaid Provider Enrollment Application Guide and Web site at the bottom of the page, or contact the tax representative in the Code of Practice. 13. Enter the appropriate two-digit code(s) to identify your service category(s) in the Medicaid Provider Enrollment Application Guide, website listed at the bottom of the page , or contact a tax agent. Select the appropriate service category and call the tax agent Service Code List 14. NPIN and UPIN, if applicable Form NPIN UPIN AHCA (December 2002) Page 5

6 15. Medicare Number 16. Include current and legible copies of the licenses listed below: professional license, facility license, Clinical Laboratory Improvement Amendments (CLIA) license, or any combination of the three. You must print your license online from the Ministry of Health website. Note: All providers providing laboratory services must submit a legible copy of a current CLIA compliant certificate or credential and a legible and current state laboratory license with the application. Professional License Number: License Date: Expiration Date: Facility License Number: CLIA License Number: 17. Only independent providers should complete this item. Leave blank for group candidates. Enter the number of Medicaid providers assigned to any group practice you are a part of. If you do not belong to a group practice, please leave this item blank. The start date is the effective date of your Medicaid enrollment or the date you become affiliated with your group. Enter the date you became a member of the group practice in the format XX/DD/SS. Limit of 15 membership groups. a. Group Membership Information Group Provider Number: Start Date: b. Is group registration pending on this app? Yes No Application Form 6 AHCA Form (December 2002)

7 18. Enter the appropriate property code

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