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Application for Provider Enrollment and Certification (MEDCO-13)

Thank you for your interest in applying to our network.

We encourage you to use our online process by clicking Go to Online Application below. You can print, complete, and return a paper application in lieu of the online process.   

The Provider Enrollment and Certification application process applies to all providers except for group practices and certain providers rendering services in an approved vocational rehabilitation plan.

Click here to see a full list of providers eligible for network certification.

Group practices and some providers rendering services in an approved vocational rehabilitation plan should complete the Provider Enrollment Non-Certification application.

Already an active provider? Log into our secure provider portal using your e-account or use the Request to Change Provider Information paper form to make updates.

Go to Online Application