Initial Provider Application Material
Back to the Community Programs Page
Below you will find the application material for becoming a certified Medicaid Waiver provider. Please print and fill-out all documents to ensure your initial certification is completed in a timely manner.
Reminder: In order to successfully complete your application, you must contact your local Provider Support Specialist to obtain the appropriate Background Check paperwork.
ATTENTION: For all new applicants, effective August 1, 2011, there will only be one waiver provider number allowed per location.
|Division Initial Certification Packet
ACS Wyoming Enrollment Form
ACS EDI Agreement Page 1
ACS EDI Agreement Page 2
ACS EDI Agreement Page 3