Step 1: Print the following documents, complete, and obtain required signatures
Documents required to enroll as a billing provider:
- Core Provider Agreement in PDF and Word
- Debarment Form in PDF and Word
Step 2: Gather supporting documents to enroll with the Core Provider Agreement
The following documents must be sent to the agency as part of the online enrollment application process:
Step 3: Complete the online enrollment application process
You can apply to become a Washington State Medicaid provider using our online enrollment application. You need to send all required documentation and signatures. At the end of the application process, you will be given instructions for sending the necessary documents.
Access online enrollment application (site only works with internet explorer users and does not work for Health Care Authority staff)
Step 4: After completing your application:
Signatures are required on: Core Provider Agreement, Ownership, Debarment, and Electronic Funds Transfer form.
Documentation sent to Provider Enrollment requires a document submission cover sheet. You will be prompted to complete the document submission cover sheet as part of the online enrollment process.
Mail or Fax all enrollment documentation to:
PO Box 45562
Olympia, WA 98504-5562
Do not send the following:
- Double-sided documentation.
- Curriculum Vitae or Resumes'.
- Copies of drivers' licenses or passports.
Your application will be processed in the order it is received. All supporting documentation must be received to complete the review and verification of your application. Once you receive your ProviderOne ID and security information, you are a current Washington Medicaid provider.
Step 5: Check the status of your enrollment application online.
If you started an online enrollment but have not completed the required steps, you may track your online enrollment application (link does not work for Health Care Authority staff) by using the system generated Application ID, and the SSN or FEIN you entered on the enrollment. This allows you to complete the enrollment and submit it to DSHS for review and approval.
What to expect after submitting an application:
- Applications submitted on-line: Expect up to 30 days to process.
- Applications submitted hard copy: Expect up to 90 days to process.
- If an application is out of state, requires program approval, is missing required information or documents, you should expect the applications to take longer to process. You will be contacted if addtional information is required.
- If your enrollment is approved you will be mailed a welcome letter.
If you have questions about your enrollment application, call 1-800-562-3022, ext. 16137, 7:30 a.m. to 4:00 p.m. PST Monday - Friday.