What forms do I need to enroll/credential?
Step #1:
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Step #2:
Download the First Steps Policy Manual:
• First Steps Policy Manual
Step #3:
Enrollment Documents for ALL Providers:
• Agency Checklist source
• Agency and Independent Provider Agreement*
• Provider Agreement (Rider A)*
• Service Coordination Agreement (Rider B)*
• Enrollment Application
*Documents marked with an asterisk (*) must be submitted annually
Step #4:
Additional Enrollment Documents for Independent Providers
• EFT Form
• Online Access Form
• W-9
• Annual Update For Exempt Providers*
*Documents marked with an asterisk (*) must be submitted annually
Step #5:
Initial Credential Documents
• Initial Credential Application
Step #6:
Annual Credential Documents
• Annual Credential Form
Other Helpful Documents:
• Handy CRO Numbers source
• Glossary of Terms source
• Policy Manual Frequently Asked Questions (FAQ)
• Credentialing Extension Request
• DT Release Form
• Independent PD Activity Approval Request
• Monthly Supervision Report
• EI Procedure Codes And CPT Cross Reference -- PDF (2019)
• EI Procedure Codes And CPT Cross Reference -- CSV (2019)
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