Provider Enrollment for Adult Cystic Fibrosis

This is a very small waiver with slots for 125 recipients state wide. As with the TBI/SCI Medicaid Waiver, only those licensed individuals (LPNs or RN's) will be considered for in-home care. New WAIVER providers [meaning, you have not applied nor are enrolled as a Waiver provider for any other waivers] will require the following:
 

After you've identified your Core Service, you will need to attach a copy of the following forms:

a. A complete Cystic Fibrosis Medicaid Waiver Application (2.13kb pdf)

b. Application Instructions (56.9 kb) [for your reading only]

c. The Medicaid Provider Agreement form http://portal.flmmis.com/FLPublic/Provider_Enrollment/tabId/50/Default.aspx and then

     http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/ENROLLMENT/MPA_Non-Inst_April_10.pdf.

d. Documentation of Provider Qualifications (56.68 kb)

e. National Provider Identifier Application NPI Registration  NPI CMS Notice

f.  Copy of drivers license, social security card and/or W9 as required;

g. Any other supporting documentation and licenses as required in the Core Service.
 

Core Services

All documents are PDF files less than 3mb and less than 20 pages. All open in a new window.

                WAIVER PROVIDERS ALREADY ENROLLED AND ACTIVE WITH ANOTHER WAIVER

If you are already enrolled and an active provider with another waiver, these will be the only forms you will need:

1. Electronic Data Interchange Agreement (37.32 kb)

2. Application for New Location Code  (48.07kb)

3. Electronic Funds Transfer Authorization  (40.49kb)      [Option #1 must be filled out, together with the letter as noted].

4. Attach all other supporting documentation and licenses as required in the Core Service, along
    with a copy of your drivers license, social security card;

5. A copy of your W9 if applicable.