Request Information
Validation Summary

You are initiating a provider enrollment application for the Pennsylvania Department of Human Services (DHS) Medical Assistance (MA) program and/or the Pennsylvania Children's Health Insurance Program (CHIP). If you are enrolled as a MA provider and provide CHIP services at this service location, a separate CHIP enrollment application is not required.

If you exit the application before it has been submitted, you can resume your provider enrollment application at a later time by providing the system generated Application Tracking Number (ATN), the Federal Tax Identification Number (FEIN or SSN) and password you established.

In addition, once submitted, you can check the status of your application at any time by selecting the “Application Status” link from the PROMISe portal landing page on the left side under “Provider Enrollment”, entering the ATN, SSN/FEIN, and password fields and clicking “submit”. The Application Summary section will display on the page showing the current status of the application.

Indicates a required field.
Indicates an attachment is required.
Initial Enrollment Information
Verify your program type, provider type and enrollment type selections prior to saving this page. Once this information is saved, it cannot be changed. If this information is incorrect, you will need to begin a brand new application.
Tax Identifier
Based on the Enrollment Type selected above, you are required to specify either a Social Security Number (SSN) or Federal Tax Identification Number (FEIN). A Federal Tax Identification Number (FEIN) is used to identify a business entity. A Social Security Number (SSN) is used to identify an individual.
Name of Enrollee
Based on the Enrollment Type selected above, you are required to specify either an Entity Name or an Individual’s Name.
Medicare Enrollment Information
Contact Information

Contact information will be used for correspondence regarding this application. This is not required to be the provider’s contact information, but rather should be the contact information of the person who is completing the application and can assist with questions regarding this application. In addition, email notifications will be sent to the contact email address provided, at key points during the application process:

  • Online application initiated
  • Online application submitted
  • Online application returned to provider for revisions
  • Online application expiring

The password you enter will allow you to continue the application at a later time and to check the status of the application.

Enter 10-Digit Phone Number, including Area Code using 999-999-9999 format.
Phone
Enter a 3 or 4 digit Extension.
Enter 10-Digit Phone Number, including Area Code using 999-999-9999 format.
Toll Free
Enter a 3 or 4 digit Extension.
Enter 10-Digit Phone Number, including Area Code using 999-999-9999 format.
Enter a valid email in myemail@domain.com or my.email@domain.net format.
Enter a valid email in myemail@domain.com or my.email@domain.net format.
One Lowercase Letter
One Number
(8-20) Characters Long
One Uppercase Letter
Passwords Match