New Service Type or Address Request Form

Effective September 1, 2017, the Agency for Health Care Administration (Agency) replaced the New Location Code Request (July 2008) form with the New Service Type or Address Request Form (August 2017). Medicaid providers who are actively enrolled, have no restrictions, sanctions, or over payments, and meet all eligibility requirements can submit the New Service Type or Address Request Form to the Agency for purposes of adding a provider type to their existing provider agreement or to register a secondary location. The form includes a listing of provider types that may be requested. The New Service Type or Address Request Form (August 2017) has been posted to the Enrollment Forms page of the Medicaid public Web Portal.

Source: https://portal.flmmis.com/FLPublic/Provider_ProviderServices/Provider_Enrollment/Provider_Enrollment_EnrollmentForms/tabId/58/Default.aspx