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Note:
Enrollment with LTC is required prior to enrollment with
Carriers or Payors.
| If
you need the Adobe Acrobat Reader in order to read
the (.PDF) file format, download the free version
here first... |
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Dental
Enrollment Forms (Payor I.D.)
Medical
Enrollment Forms
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For all other Payor/Carrier additional enrollment forms not listed, please use the ENS enrollment procedure listed below.
Enrollment Forms: via ENS 
Please note (Important!):
- Be sure to print your tax I.D. on the top of the enrollment form before sending it in to ENS.
- Do not download or click on any other carrier form other than the one you are seeking.
- If the form can be faxed to ENS, DO NOT FAX to the number shown on the form. Fax to 719-785-5290.
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- Once the page loads, select the state for your carrier from the drop down list box and then click on the emc agreement .pdf form for the carrier you wish to enroll with.
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New Client
Enrollment Forms for Providers and/or Billing Centers new to LTC
| If
you need the Adobe Acrobat Reader in order to read
the (.PDF) file format, download the free version
here first... |
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Download
- Carrier or Payor Enrollment Forms
