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Download - Carrier or Payor Enrollment Forms

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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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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