Provider Enrollment Forms

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Enrolling online allows providers to complete the enrollment process through self-service screens that can be accessed here.  If you are unable to apply online, the paper forms can be submitted by mail or by fax using the Provider Enrollment Coversheet.

Providers who wish to enroll as Utah Medicaid providers must submit the following completed forms and documents.  Please retain a copy for your records.

  • Utah Medicaid Provider Agreement
  • Ownership Disclosure Definitions
  • Copy of Professional or Business License
  • Proof of Medicare Certification
    • Submit one of the following to show current participation:
      • Current letter of accreditation (JCAHO or AOA)
      • Letter from HHS, CMS, or Medicare intermediary showing current enrollment
      • National Supplier Clearinghouse letter with current service address
  • Copy of IRS Form W-9 with current Taxpayer Identification Number

Mental Health Providers:

If you are enrolling as a mental health or substance use disorder provider, please fill out the forms below in addition to the other required documents:

Dentists:

If you are a Dentist practicing in the urban areas of the state, please fill out the following form in addition to the above required documents.

Ordering/Referring/Prescribing Providers:

This applies to providers who only order, refer, or prescribe to Medicaid members. This type of enrollment does not allow Medicaid to reimburse you for your services.  If you wish to be an Ordering/Referring/Prescribing Provider, you must submit the 'Utah Medicaid Provider Application' listed above. Please retain a copy for your records.

Additional Information for Providers: