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Becoming a New Jersey Medicaid Provider
In order to enroll as a New Jersey Medicaid provider for the Division of Child Behavioral Health Services you will need to complete an enrollment package, which consist of the following forms:
- Signature Authorization Form
- Provider Application FD-20
- Provider Agreement FD-62
- Disclosure of Ownership and Control Interest Statement (CMS 1513)
Please note that for each county, in which you have an office, you will need to complete an entire enrollment package. You will eventually receive a unique seven-digit provider number for each county office.
If you have questions and can contact Unisys Provider Services at 1-800-776-6334 or the Division of Medical Assistance and Health Services' (Medicaid) Provider Enrollment Office at 609-588-2905.
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