1. Home
  2. Search

Provider Application Request

Fee-for-Service (FFS) providers should use this form to submit a request for a MassHealth provider application.

To become a fully participating provider, the application package must be completed in its entirety and submitted to MassHealth for review and approval.

MassHealth will notify you in writing of its decision about your application. Payment will not be made for any claims submitted for services, care or supplies furnished before the enrollment date authorized by MassHealth.

For MassHealth Dental or Long-Term Services & Supports (LTSS), visit:

Before submitting a request, applicants should review the MassHealth regulations and provider manuals for their provider type to ensure the requested application package is appropriate.

Applicants can also register for trainings on how to complete the forms once they receive their application.

* indicates a required field