Individual

Use these steps to begin an application on behalf of a Provider enrolling as an Individual:

From the Provider tab, select the New Enrollment hyperlink.

The System displays the New Enrollment page.

Select the Individual radio button.
Select the Submit button.

The System displays the Basic Information page.

Select a Provider Type.

Note: The Provider Type that you select may change which fields are required.

Select a Program.
Select a Tax Identifier Type.

Note: The Tax Identifier Type that you select may change which fields are required.

Enter the required information based on your previous selections.
Select the Submit button.

The System saves the new enrollment and displays the Basic Information page.

Important Note: The System displays a message providing the Application #. Make note of this number as it, along with the SSN or FEIN, is required to track the enrollment application.

Select the OK button.

The System displays the Enroll Provider -Individual page.

Individual

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