How to Apply

(Each of the following five is required as a first time applicant.)

1. Application Checklist (pdf 56.45kb)
2. Provider Application Instructions (For first time applicants only) (pdf 51.91kb/4 pages)
3. TBI/SCI Medicaid Waiver Application (pdf 2.09mb/13 pages)
4. Non-Institutional Provider Agreement Form (94.19kb/3 pages)
5. NPI Registration Application (pdf 546.65kb) (only use if you have not previously filled out)

Information for Providers Already Enrolled in Another WAIVER

1. Application for a New Location Code (pdf 44.17kb/2 pages)
2. Payment Method Authorization Agreement (pdf 37.32kb/2 pages) [sign under OPTION #2, everything else remains blank]
3. NPI CMS Notice (pdf 38.52kb/3 pages)
4. All applicable licenses, certifications and other proof of qualifications as required.
5. NPI Registration Application (pdf 546.65kb) (only use if you have not previously filled out)
6. Group Membership Authorization (pdf 23.12kb)

For additional information on provider enrollment for the TBI/SCI Medicaid Waiver please call your local Medicaid Waiver Specialist or this office at the number provided below.

You can follow the status of your application by going to http://portal.flmmis.com/FLpublic/default.aspx and clicking on Provider enrollment for more information.

IMPORTANT ENROLLMENT INFORMATION - PLEASE READ THOROUGHLY

Medicaid Referral Agreement (pdf 54.79kb/6 pages)
TBSCI Rates 10/7 as of 8-5-09 (pdf 20.46kb)
TBS/SCI Handbook

• Copies of certification, licenses and credentials for specific service areas are required at the time of application submission. [See Core Services for specifics].
• All individual providers are required to hand write a note describing familiarity and experience in working with individuals who have sustained a traumatic brain and/or spinal cord injury.
• You may obtain a fingerprint card by contacting your local Medicaid office at http://www.fdhc.state.fl.us/Medicaid/Areas, by contacting your local TBI/SCI Medicaid Waiver Specialist or by calling the toll free number listed below.
• Refer to the Application Checklist.

For New Providers

Florida Medicaid offers a Web portal which provides communication, data exchange, and self-service tools to the provider community. The portal consists of both public and secure areas. The public area contains general information such as program awareness, notices and forms, and allows users to respond to surveys. The secure area allows access to your personal information and offers the following options:

• View information found on your provider file;
• View contact information;
• View training schedules and locations using the Area Office contact page; and
• Receive training using computer-based training (CBT) courses.
• Request eligibility verifications,
• Request and track prior authorization and referrals.
• Submit and track claims;
• Receive alerts and claims;
• Receive Medicaid policy updates and
• Request changes to your provider file.

Please visit http://portal.flmmis.com/FLPublic/Provider_Home/tabId/36/Default.aspx to learn how you can enroll to obtain access to Medicaid's provider community of information.

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Department of Health
Brain and Spinal Cord Injury Program
4025 Bald Cypress Way, Bin C25
Tallahassee, Florida 32399-1744

Program Toll Free Number
(866) 875-5660
Program Fax Number
(850) 921-0499