Skip Navigation Links Wyoming Department of Health

IMPORTANT NOTICE: Many pages on this site may not display properly for Internet Explorer 11 users. Please consider another browser such as Chrome or Firefox.

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
(Temporarily down)

ACS Wyoming Enrollment Form

ACS EDI Agreement Page 1

ACS EDI Agreement Page 2

ACS EDI Agreement Page 3

WOLFS 109a