Step 1: Print the following documents, complete, and obtain required signatures.
Documents required to enroll with the Core Provider Agreement:
- Core Provider Agreement in PDF and Word
- Debarment Form in PDF and Word
To enroll as Nonbilling Individual Provider:
Individual healthcare professionals who wish to enroll for the sole purpose of ordering, referring and prescribing services for Washington Medicaid clients may enroll as a Nonbilling Individual Provider. The Nonbilling Individual Provider Agreement should not be used to enroll with the intent to submit claims for reimbursement. For additional information, refer to the Nonbilling Individual Provider Agreement and WAC 182-502-0006.
Note: Any existing Core Provider Agreement and/or any enrollment under a group of providers for the individual will be terminated and replaced by the Nonbilling Individual Provider Agreement.
The following documents must be sent to the agency to enroll as a Nonbilling Individual Provider:
- Nonbilling Individual Provider Agreement in PDF and Word
- Copy of Liability Insurance
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.
There is help available on each screen as you move through the application. If you have any questions, you may contact our customer service at 1-800-562-3022, ext. 16137.
Access online enrollment application (link 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. If you have questions about your enrollment application, call 1-800-562-3022, ext. 16137, 8 a.m. to 4:30 pm PST Monday - Friday.
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.
If your enrollment is approved you will be given a new ProviderOne id. You will also need security credentials to log into ProviderOne. Please complete the Provider Supplemental Information Form to request a ProviderOne user id and password. Once you have these credentials you can log into ProviderOne at (https://www.waproviderone.org/).
For more information on managing your provider file, go to:
Timelines to process applications:
- 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.