016.06.11 Ark. Code R. 021
DIVISION OF MEDICAL SERVICES
MEDICAL ASSISTANCE PROGRAM
PROVIDER APPLICATION
As a condition for entering into or renewing a provider agreement, all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.
Whenever changes in this information occur, please submit the change in writing to:
Medicaid Provider Enrollment Unit
HP Enterprise Services
P.O. Box 8105
Little Rock, AR 72203-8105
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the applicant:
Electronic Fund Transfer - All Providers (optional)
Managed Care Agreement - Primary Care Physician
W-9 Tax Form - All Providers
Contract - All Providers
Ownership and Conviction
Disclosure - All Providers
Disclosure of Significant
Business Transactions - All Providers
016.06.11 Ark. Code R. 021