Limited Enrollment Provider

This type of enrollment is for providers who order, refer, or prescribe to Medicaid clients. This type of enrollment does not allow Medicaid to reimburse you for your services. For more information, please call Provider Enrollment at 1-801-538-6155, or toll-free 1-800-662-9651 (option 3 then 4).

Providers who wish to enroll as an ordering, referring, or prescribing provider must fill out each required document in its entirety and mail or fax to the address below. Please write on top of application whether you are an ordering, referring, or prescribing provider.

Mailing Address:
Bureau of Medicaid Operations
Provider Enrollment
P.O. Box 143106
Salt Lake City UT 84114-3106

Fax: (801) 536-0471