Florida Medicaid Provider Enrollment App Guide - Version 2 - April 2021

Sep 19, 2026

Florida Medicaid Provider Enrollment Application Guide (Version 2.0, April 2021) provides a comprehensive reference for applicants completing provider enrollment through the Florida Medicaid online enrollment wizard. It outlines the guide’s purpose and covered contents, explains enrollment qualifications, accuracy requirements, and supporting documentation expectations. The guide details pre-enrollment steps, application submission navigation and sections, certification and attestation panels, identifying information, service and mailing addresses, EFT and collaboration agreements, document management, and procedures for confirming or correcting application status and maintaining provider information.

LanguageEnglish

CategoryForms

FormatPDF

Pages24

Reading Time8 min

AccessFree to download

Purpose

Contents

General Information

Enrollment Qualifications

Accuracy of Information

Supporting Documentation Requirements

Enrollment Process

Before You Enroll

Submitting a Provider Enrollment Application

Navigation

Enrollment Type

Enrollment Type Confirmation

Application Tips

Request Type

Identifying Information

Certification and Attestation Panel

License & More Identifying Information

Collaboration Agreement

Contact Information

Service Location

Mailing Address

Pay To Address

Home/Corp Office Address

Supporting Documents

Certification

Application Confirmation

Verifying the Status of an Enrollment Application

Application Status Descriptions

Submitting Corrections to a Pending Application

Maintaining Provider Information

Helpful Resources

Florida Medicaid Provider Enrollment Application Guide Version 2.0 | April 2021 Table of Contents 1 Purpose ........................................................................................................................................... 1 2 Contents .......................................................................................................................................... 1 2.1 General Information ........................................................................................................ 1 2.2 Enrollment Qualifications ................................................................................................ 1 2.3 Accuracy of Information .................................................................................................. 2 2.4 Notice Regarding Use of Social Security Number .......................................................... 2 2.5 Supporting Documentation Requirements ...................................................................... 2 2.6 Enrollment Process ......................................................................................................... 2 3 Before You Enroll ........................................................................................................................... 2 4 Submitting a Provider Enrollment Application............................................................................ 3 4.1 Navigation ....................................................................................................................... 3 4.2 Welcome Statement ........................................................................................................ 3 4.3 Enrollment Type .............................................................................................................. 3 4.4 Enrollment Type Confirmation ......................................................................................... 4 4.5 Application Tips ............................................................................................................... 4 4.6 Request Type .................................................................................................................. 5 4.7 Before You Continue ....................................................................................................... 6 4.8 Identifying Information ..................................................................................................... 6 4.9 Certification and Attestation Panel .................................................................................. 7 4.10 License & More Identifying Information ........................................................................... 7 4.11 Collaboration Agreement ................................................................................................ 8 4.12 Contact Information ......................................................................................................... 8 4.13 Service Location .............................................................................................................. 8 4.14 Mailing Address ............................................................................................................... 9 4.15 Pay To Address ............................................................................................................... 9 4.16 Home/Corp Office Address ............................................................................................. 9 4.17 Xref NPI ......................................................................................................................... 10 4.18 ATN Information ............................................................................................................ 10 4.19 Member of the Following Groups .................................................................................. 11 4.20 Billing Agent Agreement.

FAQs

What is the purpose of this Florida Medicaid provider enrollment application guide?

It serves as a comprehensive reference to help applicants complete the Florida Medicaid provider enrollment process using the online enrollment wizard, tying together related publicly available portal information.

What should applicants do before enrolling?

Applicants should review the “Before You Enroll” section and ensure they understand enrollment qualifications, accuracy requirements, and supporting documentation needs before starting the application.

How can applicants submit and later correct a provider enrollment application?

The guide explains how to submit an enrollment application through the wizard, how to verify application status and status descriptions, and how to submit corrections to a pending application.

Sep 19, 2026

Upload by Oliver Hayes