STATE OF MARYLAND
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
MEDICAL CARE PROGRAM
Please fill in the requested information as completely as possible. The following form definitions are provided to help clarify the information
Should you have any questions please contact the Provider Enrollment Unit at (410) 767-5340.
NOTE: PLEASE ATTACH A COPY OF ALL REQUESTED
1) APPLICATION TYPE
Check the appropriate box. If the request is to change existing data, then you
must also include your Medicaid Provider Number. If you have already
rendered service please indicate a Requested Enrollment Begin Date. The
Provider Enrollment Unit will backdate your application up to (3) months
prior to its receipt date. The enrollment begin date for an approved application
is based on the date the application is received in our office.
2) PROVIDER INFORMATION
If you have a business, such as pharmacy or medical supply, or a professional
group, enter the company name or corporate group name. All physicians and
other individual practitioners should enter last name, first name, middle initial
and professional title.
Enter the address, telephone and fax number of your primary practice
location, contact person name and their telephone number and the practice
email or website address. Enter a “Y” for Yes or a “N” for No if your office is
Enter the appropriate two-digit code for county of your business or practice
location address. A listing of the county codes is provided for your reference
at the end of these instructions.
Enter the two-digit code for the appropriate provider type from the listing
provided at the end of these instructions. Applicants for the Kidney Disease
Program (KDP) must also enter the two-digit KDP code.
Enter the Federal Employer ID Number, National Provider Identification
(NPI) and the Social Security Number of the individual, group or business to
whom the Medicaid reimbursements will be made.
3) LICENSE/PERMIT INFORMATION
Enter your professional license number, beginning effective date and
expiration date for each practice location in which you service Maryland
Medicaid recipients. If out of state, attach a copy of the current license
certificate. Enter your NABP number if applicable.
Enter your Drug Enforcement Agency number and attach a copy of your DEA
certificate. If you do not have a DEA number, this box should be left blank.
Enter your pharmacy permit number, if applicable.
Medical laboratory providers, practitioners and other providers that perform
medical laboratory services MUST COMPLETE and SUPPLY the
• Enter Clinical Laboratory Improvement Amendment (CLIA) #
• Attach a copy of CLIA Certificate
• Enter Maryland Laboratory Permit or Letter of Permit Exception #
• Attach copy of Maryland Laboratory Permit or Letter of Permit
Out-of-state providers that do not receive specimens originating in Maryland
do not have to supply Maryland certification information but do have to state
that they do not receive specimens originating in Maryland.
Practitioners providing laboratory services to OTHER THAN THEIR OWN
PATIENTS MUST enroll as medical laboratory providers.
4) PRACTICE INFORMATION
Enter the appropriate two-digit code for your type of practice. If this does not
apply, leave blank. For your reference, a listing of the practice codes is
provided at the end of these instructions.
If you are applying as an HMO, enter FR to indicate the type of contract as
Full Risk with Abortion or SL to indicate the type of contract as Stop Loss
without Abortion. In addition, please complete and sign the enclosed form
DHMH 4126-G located at the end of the application. Otherwise, leave this
5) SPECIALTY INFORMATION
Enter a “P” to designate the primary specialty. If multiple specialty codes are
entered, then you must designate one specialty as the primary specialty.
Physicians, Dentists, and Pharmacies MUST enter the appropriate three-digit
code from the specialty code listing provided at the end of these instructions.
Enter OTH if you have another specialty not listed. PLEASE SPECIFY.
Enter the date you were certified for your specialty in MMDDYY format.
Enter the number, up to six digits, that was provided to you when you were
certified for the associated specialty.
6) SPECIALTY VERIFICATION
Please check the applicable statement and attach the required documentation.
7) GROUP MEMBERSHIP INFORMATION
If you are a MEMBER OF A GROUP PRACTICE, please enter the name,
Maryland Medicaid provider number and the effective date you became a
member of the group. If you are a GROUP PRACTICE, please list the names
of each professional practicing in your group and his/her individual Maryland
Medicaid provider number and membership effective date. All practitioners in
the group MUST individually be enrolled as a Maryland Medicaid provider.
8) MEDICARE INFORMATION
If you participate in Medicare, please list the fiscal intermediaries with whom
you are enrolled (i.e. Blue Cross of Maryland, Traveler’s Group Hospital
Insurance, etc.) and enter the provider number each has assigned to you.
9) ALTERNATE ADDRESS INFORMATION
Enter the Pay-To-Address address, you want your Medicaid reimbursement
checks mailed. If you leave this section blank, your checks will be mailed to
the primary practice location entered on the first page of the application.
Enter the Correspondence Address you want all your Medicaid related
correspondence and remittance advices mailed. If you leave this area blank,
correspondence will be mailed to the primary practice location entered on the
first page of the application. Also, please indicate if you would like to receive
correspondence electronically. If yes, please include your email address on the
first page of the application.
10) OTHER PRACTICE LOCATION INFORMATION
Please enter other locations where you serve Maryland Medicaid recipients.
Include all group addresses where you are currently practicing. Enter a “Y”
for Yes or a “N” for No if your office is handicap accessible.
Please sign and date the application. No one can sign on your behalf.