Provider Enroll

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Enroll as a Utah Medicaid Provider

Thank you for your interest concerning participation in the Utah Medicaid Program. The set of forms below outline procedures to enroll as a Utah Medicaid provider. For more information, please call Provider Enrollment at 1-801-538-6155, or toll-free 1-800-662-9651.

Providers who wish to enroll as Utah Medicaid providers, please complete the forms and mail or fax to the address below. You will be notified approximately three weeks from the receipt of all required documentation of the results of your application.

Utah Medicaid Provider Application (please retain a copy for your records)
Instructions for completing the provider application.
Utah Medicaid Provider Agreement (2002), signed and dated.
Note: As a resource to help you comply with Section II, page 5, paragraph 12 Criminal Disclosure, see the List of Excluded Individuals/Entities (LEIE).
Ownership Disclosure Form
Civil Rights Protections and Free Interpreter Services
Direct Deposit Authorization Form for Electronic Funds Transfers (EFT) Electronic Funds Transfer is mandatory for all new Utah Medicaid providers.
Copy of professional or business license (See page 2 of the instructions for completing the provider application, item 2 of this list.)
Proof of Medicare Certification for Institutional providers (See page 2 of the instructions for completing the provider application, item 2 of this list.) AND one of the following to show current participation:
- Current letter of accreditation (JCAHO or AOA)
- Letter from HHS, CMS, or Medicare intermediary showing current enrollment
- Current Medicare EOB
Copy of IRS Form W-9 with current Taxpayer Identification Number
(See Box 8 on page 2 of the instructions for completing the provider application, item 2 of this list.)
Ownership Disclosure information

Mailing Address:
Bureau of Medicaid Operations
Provider Enrollment
P.O. Box 143106
Salt Lake City UT 84114-3106

Fax: (801) 538-6805

To receive a Utah Medicaid Provider Manual, complete the order form you will receive with your Medicaid Provider Number notification letter. The manual contains information on general policy, limitations of coverage, and reimbursement policy for your specific type of service. The Provider Manual also includes instructions for completing claim forms, an example and explanation of the remittance statement, and a description of Medicaid’s automated payment system. Click here to access the online Utah Medicaid Provider Manuals.