Get the free Out-of-State Provider Express Enrollment Form 23enrollment DHCSMC4603 - files medi-c...

State of CaliforniaHealth and Human Services Agency Department of Health Care Services JENNIFER KENT Director EDMUND G. BROWN JR. Governor OutofState Provider Express Enrollment Form Dear OutofState

How to fill out out-of-state provider express enrollment

How to fill out out-of-state provider express enrollment:

1. Go to the website of the provider express enrollment portal.
2. Click on the option for out-of-state enrollment.
3. Fill in your personal information such as name, address, and contact details.
4. Provide your professional credentials and qualifications.
5. Specify the state in which you are currently licensed as a healthcare provider.
6. Upload any required supporting documents such as your license or certifications.
7. Review all the information you have entered and make sure it is accurate.
8. Submit your application and wait for a confirmation or notification from the portal.
9. Follow any additional instructions or requirements given to complete the enrollment process.

Who needs out-of-state provider express enrollment:

1. Healthcare providers who are licensed in one state but want to practice or provide services in another state.
2. Providers who will be treating patients or offering healthcare services on a temporary or occasional basis in another state.
3. Providers who want to join a network or organization that operates in multiple states and requires enrollment in each state.

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What is out-of-state provider express enrollment?

Out-of-state provider express enrollment is a process for healthcare providers who are located outside of a specific state to enroll in that state's Medicaid program quickly and easily.

Who is required to file out-of-state provider express enrollment?

Healthcare providers who are located outside of a specific state and wish to provide services to Medicaid beneficiaries in that state are required to file out-of-state provider express enrollment.

How to fill out out-of-state provider express enrollment?

Out-of-state provider express enrollment can typically be completed online through the state's Medicaid website by providing necessary information about the provider and their services.

What is the purpose of out-of-state provider express enrollment?

The purpose of out-of-state provider express enrollment is to streamline the process for out-of-state healthcare providers to enroll in a state's Medicaid program and begin providing services to beneficiaries.

What information must be reported on out-of-state provider express enrollment?

Information such as provider identification, services offered, contact information, and any relevant certifications must be reported on out-of-state provider express enrollment.