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Application for Provider Enrollment Non-Certification (MEDCO-13A)

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 Non-Certification application process applies to only the following provider types:

  • Group practice (12) 
  • Approved vocational rehabilitation plan.
    • University and college services (78).
    • Rehabilitation: non-credentialed services (79).
    • Retail store (80).
    • Rehabilitation: unsupervised conditioning facility (81).
    • Rehab transportation (taxi, bus, and air travel) (83).
    •  Interpreter services (99).

Providers who are not in a category listed above should complete the Provider Enrollment and Certification application.

Already an enrolled provider, log into our secure provider portal using your e-account to make updates.

Go to Online Application