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Ancillary Institutional Providers

Provider Application

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

Ancillary Institutional Providers:
  • Ambulance
  • Assisted Reproductive Technology
  • Behavioral Health Hospital*
  • Chronic/Long Term Care Hospital
  • Community Mental Health Center*
  • Durable Medical Equipment
  • Home Health Care
  • Hospice
  • Radiation Oncology Facility
  • Skilled Nursing Facility
  • Transitional Care Unit
  • Ambulatory Surgi-Center
  • Behavioral Health Facility*
  • Cardiac Rehabilitation
  • Clinical Laboratory
  • Dialysis
  • Early Intervention
  • Home Infusion Therapy
  • Independent Physiological and Diagnostic Lab
  • Rehabilitation Hospital
  • Sleep Study Facility
  • Urgent Care Center

* These provider types must upload the Behavioral Health for Children and Adolescents form as an attachment when they fill out the Provider Application. (Before you enter the Provider Application, complete and save the Behavioral Health for Children and Adolescents form.)