To Become a Washington Medicaid Provider

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This is the process accredited practitioners must follow to become Washington Medicaid providers.

Please TYPE or PRINT clearly when submitting a Provider Application and Core Agreement along with the documents and licenses required. If we cannot read the application it will delay your enrollment.

For a successful application, please review the following information before you submit your material.

1. NEW!!! Complete the NEW Core Provider Agreement and Provider Enrollment Application
   (DO NOT USE OLD APPLICATION!)
   • Step by Step Instructions
   • Frequently asked questions regarding Debarment
     Washington state law requires that you use the official Medicaid Core Provider Agreement and Provider Enrollment Application forms.

   We do not accept Washington Practitioner Applications.

   Do not send the following:
   • Double-sided applications.
   • FAXed applications. (We must have original signatures.)
   • Curriculum Vitae or Resumes'
   • Copies of drivers' licenses or passports

   
   
2. General Supporting Documents:
   • Copy of Current Professional License
   • Copy of Drug Enforcement Administration (DEA) certification (if applicable)
   • Copy of State Business License (If your state doesn't require a business license include a memo stating that it is not required.)
   • Copy of Internal Revenue Services (IRS) Form W-9.
   • Copy of Medicare certification letter
   • National Provider Identifier (NPI)
   • Licensed Midwives must attach Midwives Questionnaire to Completed Core Provider Agreement and Provider Enrollment Application. (Questionnaire)
   
   
3. Practice-Specific supporting documents:
   • Ambulatory Surgery Centers
   • Dentists
   • Home Health Agency
   • Hospitals and Labs
   • Psychiatrists
   • Registered Nurse First Assist (RNFA) (Surgical Assists)
4. 
   Staple once, sign and mail original application to:

   Provider Enrollment PO Box 45562 Olympia, WA 98504-5562

   For Questions call: 1-800-562-3022 option 2, then option 5

5. Sign up to conduct business electronically with WaMedWeb and Electronic Funds Transfer

   • Register for WAMedWeb to check Client Eligibility online and file electronic claims
   • Electronic Funds Transfer Form to sign up for direct deposit of Medicaid reimbursements
   
   
6. After you send us your Core Provider Agreement and Enrollment Application, we will review it. The review and verification process takes 4-6 weeks. Once you receive a seven-digit provider number, you are a current Washington Medicaid provider. If you have questions about your enrollment application, call 1-800-562-3022, option 2, then option 5, 7:30 am to 4:30 pm PST Monday - Friday.

Reminder!!! Washington state law requires that you use the official Medicaid core agreement and forms. We do not accept Washington Practitioner Applications.

Do not send the following:

• Double-sided applications.
• FAXed applications. (We must have original signatures.)
• Curriculum Vitae or Resumes'
• Copies of drivers' licenses or passports

If you have questions about the enrollment process, contact us via email or call 1-800-562-3022, option 2 then option 5 7:30 am to 4:30 pm Monday - Friday.

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Page modified: November 2009       

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