Enrollment Forms
NOTE: This information will be updated with the implementation of the new provider enrollment system, which is scheduled for April 2026. To stay informed about the transition effort, sign up for Florida Medicaid Health Care Alerts.
Medicaid Provider Agreements (MPA) MPA Guide
Institutional Medicaid Provider Agreement
Institutional Medicaid Provider Agreement - Intermediate Care Facility for the Developmentally Disabled (ICF/DD)
Institutional Medicaid Provider Agreement for Qualified Hospitals Electing to Make Presumptive Eligibility Determinations
Non-Institutional Provider Agreement
Medicare Crossover-Only Provider Agreement
Certificate of Ownership
Physician Group Certificate of Ownership Form
Change of Ownership
Hospital, Skilled Nursing Facility (SNF), and Intermediate Care Facility (ICF) Reporting a Change of Ownership:
AHCA Form 5000-1264 Change of Ownership Disclosure Form Disclosure Form Instruction Guide
To report changes in ownership that are less than 51%:
Change in Ownership Disclosure Tool Disclosure Tool Instruction Guide
Additional Enrollment Forms
Group Membership Authorization Form
Practitioner Collaborative Agreement (For ARNP, AA, PA, CRNA, RNFA Providers)
NPI Registration Form NPI Registration Form Guide NPI QRG
Electronic Funds Transfer Authorization Agreement Electronic Funds Transfer Enrollment Guide
Physician Specialty Training Attestation
Medicaid Pharmacy Point of Service Vendor Certification and Claims Submission Authorization Form
Surety Bond Form
Non-profit Organization Certification Fingerprinting Exemption
Special Exempt Entity Certification Fingerprinting Exemption
Florida Medicaid Provider Enrollment - Clearinghouse Providers Only
Mental Health Targeted Case Management - Provider Type 91 Case Management Agency
Appendix B - Agency Certification - Children's Mental Health
Appendix C Agency Certification - Adult Mental Health
Appendix D Agency Certification, Intensive Case Management Team Services - Adult Mental Health
Mental Health Targeted Case Management - Provider Type 91 Case Management Agency and Provider Type 32 Social Worker/Case Manager
Appendix E Case Management Supervisor Certification - Children's Mental Health
Appendix F Case Management Supervisor Certification - Adult Mental Health
Out of State Enrollment Forms
Out of State Provider Enrollment Application
Additional Resources
Florida Medicaid Contact Information Sheet
Support
Training
AHCA Adopted Rules
AHCA Medicaid Forms
Provider Enrollment Policy incorporated by reference in Rule 59G-1.060, F.A.C.
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