Contact your State Agency to obtain an application. Links to the forms are also available on this site . Even if you do download an application from this website, the State Agency must still be contacted in order to initiate the enrollment process. If your facility has been accredited by this organization, please mark the box accordingly.
Entities operating under the control of a parent organization are provider based.
If another corporation owns your facility, then disclose information about that corporation. If your facility is non-profit with no defined owners, state this in Section 8 and complete section for all board members. The IRS Form CP 75 is the letter you received from the IRS granting your Employer Identification Number. Social Security numbers must be provided for all persons listed in this section. The contact person should be the person who is responsible for ensuring completion of the enrollment process for your facility.