Provider Enrollment Forms

Enrolling online allows providers to complete the enrollment process through self-service screens that can be accessed HERE.  Effective May 14, 2020 the PRISM Fax Cover Sheet will no longer be available. You may continue to fax documents for Provider Enrollment, including the provider’s name and NPI, to 801-536-0471 or 801-323-1574.

• Provider User Access Agreement
• PRISM Access Agreement
• W-9 Form

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:

• Unlicensed Mental Health and Substance Use Disorder Providers’ Form
• Addendum – Licensed Substance Use Disorder Residential Treatment Programs with 17 or More Beds Form

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.

• Dental Agreement for Urban Dentists

Additional Information for Providers:

• Medicaid Sanction Policy
• Nondiscrimination Policy