How to apply for an Adult Family Home Medicaid Contract

  • Email with the request for Medicaid Contract with the following information:
    • Facility Name
    • Facility License number
    • Facility address
  • Once the Contracts Unit is notified of the request the following forms will be emailed to the provider for completion; or the provider can complete these forms prior to request and submit completed forms with request for Medicaid contract:
  • Once all forms are returned and processed the contract manager will email provider copy of contract for review and signature. 
  • Provider will return signed copy of contract.
  • Contract staff will sign and return a fully executed copy of contract to provider with notification of ProviderOne number.
  • Healthcare Authority will contact provider with login instruction by email.  If email from HCA is not received within 24hr after fully signed contract is received the provider can contact HCA for login credentials (800-562-3022).
Page Topic: 
Medicaid Contracts
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