To Add a New Washington Medicaid Provider to an existing agreement

Please TYPE or PRINT clearly when submitting a Provider Application and Core Agreement along with the documents and licenses required. If we cannot read the application it will delay your enrollment.

For a successful application, please review the following information before you submit your application.

For adding a provider to an existing agreement, you need to submit the following documents:

• NEW!!! Complete the New Core Provider Agreement and Provider Application
  (DO NOT USE OLD APPLICATION!)
• Pages 4, 5 & 10 (if needed)
• Make sure you include your seven-digit Medicaid provider number at the top right of the application.
• Copy of current professional license
• Copy of Drug Enforcement Administration (DEA) certification (if applicable)
• In Section II, only provide information for provider being enrolled or added to group.
• In Section II, be sure to include your NPI number.
• Licensed Midwives must attach Midwives Questionnaire to Completed Core Provider Agreement and Provider Enrollment Application. (Questionnaire)