Contact Provider ServicesHelp * Required field Provider Information: * Provider Name: Field is Required! * Address Line 1: Field is Required! * Medicaid ID: Field is Required!Must be Numeric! Address Line 2: * Telephone: Field is Required!Format is not (nnn-nnn-nnnn) * City: Field is Required! * Email Address: Field is Required!E-Mail format is not correct * State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Fax: Format is not (nnn-nnn-nnnn) * Zip Code: Field is Required!Zip format is not correct Your Information: Name: Telephone: Format is not (nnn-nnn-nnnn) Choose a subject from the list below: * Subject: Other Directory of Individual Medicaid Provider Numbers LTC Form Request Medicaid Claims Inquiry/Response Form Medicaid Forms Order Provider Manual Request