EOHHS-MassHealth

Type of Application(Required)

Individual (Billing through SSN or sole proprietorship)

Entity (Billing through FEIN)

Group Practice (Billing through FEIN)

NPI(Required)

Repeated numbers will not be accepted, such as a string of zeros.

Last 4 digits of FEIN(Required)

Tax ID Type(Required)

SSN

FEIN

Change of Corporate Structure

Yes

An application is required due to a change of ownership, acquisition, etc.

Last 4 Digits of SSN(Required)

Last 4 digits of Provider FEIN(Required)

Please enter a number from 0 to 4.

Apply to be a Primary Care Clinician Plan provider

Yes

Select Individual Provider Type(Required)

Select Entity Provider Type(Required)

Contact Name(Required)

First Last

Contact Email(Required)

All correspondence will be sent to this email address

Contact Phone(Required)

Provider Name(Required)

First Last

Provider Business Name(Required)

Application Package Delivery Options(Required)

Receive a digital copy of the application package

Receive a physical copy of the application package

Mailing Address (Please enter the address where you would like the application to be mailed.)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please note that completion of a provider's application in full is required to ensure that it is processed.

Providers applying to participate in MassHealth will be required to complete an application, contract, and potentially additional enrollment forms. These forms may include but are not limited to an Electronic Funds Transfer (EFT) Form, Federally Required Disclosure Form (FRDF), W-9, Trading Partner Agreement (TPA), etc.