Thank you for choosing to enroll as a Montana Health Care Programs (Montana Medicaid, HMK/CHIP, Dental or Extended Mental Health and/or MHSP) provider.
The paper enrollment documents are below. If you prefer to enroll online, access the Montana Access to Health Web Portal.
If you have questions, contact Provider Relations at 1-800-624-3958
406-442-1837 or firstname.lastname@example.org.
P.O. Box 4936
Helena, MT 59604
(800) 624-3958 In/Out of State
(406) 442-1837 Helena
- Montana Health Care Programs Enrollment Application
The entire enrollment application (56 printed pages).
Additional Owner/Manager Page
Individual Sections of Application
- Cover Letter and Checklist
- Disclosures, Screening, and Enrollment Requirements
- Montana Health Care Programs Provider Enrollment Application
- Montana Health Care Programs Agreement and Signature Page
- License, CLIA, and Certification
- Trading Partner Agreement
- W-9 Form
- Montana Medicaid EFT and ERA Authorization Agreement
- Passport and Team Care Agreement
- CHIP Dental Provider Agreement and Signature
- CHIP Provider Agreement and Signature for Extended Mental Health Benefits for Children with SED
- Mental Health Services Plan Addendum
- CSCT Services Contract
- Exhibits: Statement of Work and Payment Schedule
Addendums and Other Enrollment Documents
- 72-Hour Presumptive Eligibility Program Provider Enrollment Addendum (08/2008)
- Electronic Billing Agreement (02/2009)
- Medicaid Provider