Fee-For-Service

New providers are required to complete a Medicaid Provider Application/Change Request Form (DHS 1139 Rev 02/14) to enroll as a provider in the Medicaid Fee-For-Service (FFS) Program.

Existing providers are required to complete a Medicaid Provider Application/Change Request Form (DHS 1139 Rev 02/14) if there are any changes to the information.

  • Medicaid Provider Application/Change Request Form (DHS 1139 Rev 11/17)
  • DHS 1139 (Rev. 11/17) Form Instructions

  • Psychiatry/Psychology Credentialling Atachment Form (DHS 1139A)
  • DHS 1139A Form Instructions

  • Non-Emergency Ground Transportation - Taxi Cabs Attachment Form (DHS 1139B)
  • DHS 1139B Form Instructions

  • Home Health Services Attachment Form (DHS 1139C)
  • DHS 1139C Form Instructions

  • Acute Hospital Attachment Form (DHS 1139D)
  • DHS 1139D Form Instructions

  • Nursing Facility Attachment Form (DHS 1139E)
  • DHS 1139E Form Instructions

  • Intermediate Care Facility For The Mentally Retarded (ICF-MR) Attachment Form (DHS 1139F)
  • DHS 1139F Form Instructions
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