Provider Enrollment on the Portal Instructions
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These pages will guide you through each stage of the enrollment process using PEP. To customize this page's content, use the filters below and click the Apply Filters button.

Application Type:

Program(s):

Enrolling As:

Provider Information Form (PIF-1) - Revalidation

Instructions for Completing the Provider Information Form (PIF-1).

  • Enter your or the enrolling provider’s driver’s license or other number.
  • If your driver’s license is expired or you do not have one, any current government-issued photo identification card number can be entered.
  • This field is not required for groups or facilities.
  • Enter the expiration date of your driver's license or other form of identification.
  • Your driver’s license or other form of identification must be current on the date that you submit this application.
  • This field is not required for groups or facilities.
  • Select the state of issue for your driver’s license or other form of identification.
  • This field is not required for groups or facilities.
  • Choose your Gender.
  • This field is not required for groups or facilities.
  • Click Add under “Professional License/Certification/Accreditation” to add all of the professional licenses, certifications, or accreditations that are applicable for your provider type.
    • Select Licensure, from the drop-down menu.
      •   Select an Issuer and State (out-of-state only).
      •   Enter your license number, effective date, and expiration date.
    • Select Certification from the drop-down menu.
      •   Enter the certification number that is applicable to your provider type.
    • Select Accreditation (CLIA) to enter your CLIA certification information, if it is applicable to your provider type.
      •   Enter the address listed on your CLIA certification, if applicable.
    • Select Supervising/Referring/Consulting Physician and enter your supervising physician’s information. You must provide your supervising physician license information, if you are one of the following provider types:
    • Physician Assistant
    • Independent Lab
    • Certified Nurse Midwife
    • Maternity Services Clinic
    • Family Planning Agency
    • Hearing Aid
    • Radiological Clinic
    • Click Done
  • You must answer all of the sanction questions. Your answers should reflect both past and current sanctions.
  • If you selected "Yes" for any of the questions, you must explain the details in the box below the questions. Your explanation should include:
  • The date of the sanction.
  • The state in which the incident occurred.
  • The agency that took the action.
  • The program that was affected.
 
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