Florida application medicaid enrollment 2026

1. Click ‘Get Form’ to open the Florida Medicaid Provider Enrollment Application in the editor.
2. Begin by entering your Provider Name and DBA (if applicable). Ensure that the Physical Street Address is complete, avoiding P.O. Boxes.
3. Fill in your City, State, County Name, and Zip Code. Include your Telephone Number and optional Business E-mail address for contact purposes.
4. Input your Tax ID Number (either SSN or FEIN) and Professional License if applicable. Complete the Provider Type Code and National Provider ID (NPI) fields.
5. If relevant, provide your Facility License Number, Practice Type Code, Category of Service, CLIA License Number, Ownership Code, and Specialty Code as required.
6. Review the Applicant Certification section carefully. Legibly print your name as the applicant or authorized signer, include your title, signature, and date.
7. Ensure that a representative from the Managed Care Plan has signed off on the application before submission. Make a copy for your records.

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