Location code request 2026

1. Click ‘Get Form’ to open the New Location Code Request in the editor.
2. Begin by entering your Provider Name and Base Provider Number. Ensure you include the first seven digits of your Medicaid ID followed by the two-digit suffix.
3. Fill in the New Location’s Specialty Code and Provider Type Code. Refer to the instructions on the reverse for specific codes applicable to your service type.
4. Input the New Location’s License Number if applicable, especially for Home Health Agency branches and PPEC providers, who must attach a copy of their license.
5. Complete the Service Address section, including Building/Suite Number, City, State, and ZIP code. If necessary, provide a Business Location Telephone and Fax Number.
6. If needed, fill out the Pay-To Address and Correspondence Address sections. These will default to your Service Address if left blank.
7. Finally, ensure that you sign and date the form before submission. Review all entries for accuracy.

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