Become a Medicaid Provider

Thank you for your interest in participating as a Medicaid provider. To become a Medicaid provider, you must complete and submit the required forms and documents. If you do not wish to be reimbursed by Medicaid for your services but would still like to order, refer or prescribe to Medicaid members, you will need to complete the Limited Enrollment forms.

If you have questions, please call Provider Enrollment at (801) 538-6155, or toll-free 1-800-662-9651 (option 3 then 4). Please submit your application and documentation:

By Mail:
Bureau of Medicaid Operations Provider Enrollment
P.O. Box 143106
Salt Lake City, UT 84114-3106

By E-Mail:

By Fax:
(801) 536-0471

Formal Enrollment as a Utah Medicaid Provider

Limited Enrollment Provider

Provider Approval Letter

Physician Enhancement and Self-Attestation