Transcription of STATE OF MARYLAND
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STATE OF MARYLAND
STATE OF MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE MEDICAL CARE PROGRAM provider APPLICATION (Revision Date 5/16/11) Please fill in the requested information as completely as possible. The following form definitions are provided to help clarify the information requested. Should you have any questions please contact the provider Enrollment Unit at (410) 767-5340. NOTE: PLEASE ATTACH A COPY OF ALL REQUESTED DOCUMENTS 1_____ 1) APPLICATION TYPE Check the appropriate box. If the request is to change existing data, then you must also include your Medicaid provider Number. If you have already rendered service please indicate a Requested Enrollment Begin Date. _____ 2) provider INFORMATION If you have a business, such as pharmacy or medical supply, or a professional group, enter the company name or corporate group name.
A listing of the county codes is provided for your reference at the end of these instructions. Enter the two-digit code for the appropriate provider type from the listing
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