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Ancillary Institutional Providers
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.

Provider Application

Before you enter the Provider Application, complete and save the required form for your provider type.

Ancillary Institutional Providers:
  • Ambulance1
  • Assisted Reproductive Technology1
  • Behavioral Health Hospital2
  • Chronic/Long Term Care Hospital1
  • Community Mental Health Center2
  • Durable Medical Equipment1
  • Home Health Care1
  • Hospice1
  • Radiation Oncology Facility1
  • Skilled Nursing Facility1
  • Transitional Care Unit1
  • Ambulatory Surgi-Center1
  • Behavioral Health Facility2
  • Cardiac Rehabilitation1
  • Clinical Laboratory1
  • Dialysis1
  • Early Intervention1
  • Home Infusion Therapy1
  • Independent Physiological and Diagnostic Lab1
  • Rehabilitation Hospital1
  • Sleep Study Facility1
  • Urgent Care Center1

1. These provider types must upload the Additional Site of Service form as an attachment when they fill out the Provider Application.

2. These provider types must upload the Behavioral Health for Children and Adolescents (BHCA) form as an attachment when they fill out the Provider Application. They must include all their Massachusetts-licensed sites as well as the sites used for home-based BHCA services.

Be sure to click the "Yes" button on the final screen to submit your application: