Initial Provider Application Material
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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
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ACS Wyoming Enrollment Form
ACS EDI Agreement Page 1
ACS EDI Agreement Page 2
ACS EDI Agreement Page 3
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