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Before you begin this application process, please print a copy of the Provider Information Document and keep a copy for your records. This document will assist you in the application process and administrative procedures.
You will have 30 days to complete the application online before the application becomes inactive. After completing the application, you must mail in your application fee and supplemental materials within 15 days.
Step 1: Create Account
Enter the specified information about your organization below. The password you enter will be used to log back in if you cannot complete your application in one sitting.
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