Provider Enrollment
Thank you for your interest in becoming a Montana Medicaid, MHSP or CHIP provider. This page contains all the information you need to enroll. To obtain enrollment information, download or print the files from the table below. The Enrollment Cover Letter includes a checklist of information you need to provide. If you have any questions, please contact:
Provider Enrollment
P.O. Box 4936
Helena, MT 59604
In state (800) 624-3958
Out of state and Helena (406) 442-1837
Montana's Healthcare Programs NPI
Reenrollment (for participation on or after October 1, 2007)
07/2008
Direct Deposit Sign-up
Form
06/1987
Electronic
Billing Agreement
01/2008
Electronic RA and
Payment Cycle Enrollment Form
07/2005
Enrollment Cover
Letter
01/2004
Enrollment Table
03/2005
Owner Information
Form
01/2002
CHIP Dental/Eyeglass
Enrollment Form - Short (for providers who are already enrolled
in Medicaid)
09/2004
CHIP Dental/Eyeglass
Enrollment Form - Long (for providers who are not enrolled in Medicaid)
03/1999
Mental Health Services
Plan Addendum
07/2008
72-Hour Presumptive
Eligibility Program Provider Enrollment Addendum
08/2008
W-9 Form
01/2008
Medicaid Provider
Requirements
11/2004
