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Provider Enrollment

The Adult Services Division is responsible for approving all new providers of the Choices for Care (home-based, Adult Family Care, Enhanced Residential Care) and Traumatic Brain Injury programs. This page provides an overview of the provider enrollment process by provider type and provider-specific fillable enrollment applications.


1. Before applying as a Choices for Care or Traumatic Brain Injury Provider read this: "Provider Enrollment Process Summary"

2. When you are ready to submit an application, click on the fillable application below, save a copy and fill in the form.

3. Follow all instructions for required attachments and send the form to the email on the application form.

4. If approved by DAIL, the provider will then be instructed to submit a Medicaid Provider Enrollment application with the State's Medicaid Fiscal Agent.

Non-Fillable Application Form:
Fillable Application Forms:
Additional Instructions: