CCRI Enrollment Short Form - Westmoreland County 2025

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The document is a guide for completing the Consolidated Community Reporting Initiative (CCRI) Provider Enrollment Application Short Form in Pennsylvania. It is intended for providers already enrolled in Medical Assistance Fee-for-Service or HealthChoices who wish to enroll as CCRI providers. The application requires details such as effective enrollment date, provider ID, applicant's name, provider type and specialty, license number, service location, and contact information. Completed applications must be submitted to the appropriate county representative or via email.

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Click ‘Get Form’ to open the CCRI Enrollment Short Form in our editor.
In the 'Action Requested' section, enter the effective date of enrollment and your 13-digit PROMISe™ provider ID number.
For the 'Enrollee’s Name', provide the applicant’s name and date of birth. If using a fictitious business name, attach the necessary documentation.
Fill in the 'Provider Type Number and Description' with the relevant details for your enrollment request.
Complete the 'Provider Specialty Number and Description' section by entering your specialty information.
Input your professional or state license number in the designated field if applicable.
List the physical service location where services will be provided, ensuring it is not a P.O. Box.
Indicate where you want correspondence mailed in the 'Mail to Information' section.
Finally, sign and date the application, print your name, and provide your telephone number before submitting it to the appropriate county office.

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