How to Request a Provider Enrollment Package in the Mail

You can request to receive an individual or group provider enrollment package by mail.

Optionally, you can:

• Cancel your entries. To close the page or panel without saving your changes, click Cancel.
• Reset your entries. To clear the fields and remain on the page or panel, click Reset.

To request a provider enrollment package to be mailed

1. Do one of the following:
   • On the Provider menu, click Enrollment.
   • On the Quick Links pod on the public Home page, click Enrollment.

   The Provider Enrollment page is displayed.

2. In the Become a Provider panel, click Request a Provider Enrollment Package in the Mail.

   The Request Enrollment Package page is displayed.

3. On the Request Enrollment Package page, complete the requested information.

   * indicates the field is required.

4. Verify that all information is correct.

5. Click Submit.

   An enrollment package will be sent to you within a few business days.

See Also