Maryland Department of Health
Provider Services

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ePREP Provider Agreement and Application Addenda

​Provider Agreement

All Maryland Medicaid providers must sign the Provider Agreement in ePREP at enrollment and revalidation​. View a copy of the Maryland Medical Assistance Provider Agreement​.​
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Application Addenda

Certain provider types and programs must complete and submit an addendum with their provider application. 

Use the links in the table below to access your addendum. Complete your addendum and upload it to ePREP > Applications tab >Additional Information > Practice Information. Be sure to upload any other documents requested in the addendum. 

View a full list of all provider types here​.

Addendum by Provider/Program​
PT Code
ADAA Certified Addictions Outpatient Program​​
50
Ambulance Company
T1
Ambulatory Surgical Center
39
Autism Waiver
40
​​Behavioral Health Crisis Stabilization Center
​CF
Brain Injury Waiver​
86
Centering Pregnancy Individual 
Centering Pregnancy Group​​
N/A
Clinic, Drug​
32
Clinic, Federally Qualified Health Center​​
34
Clinic, General
38
Clinic, Local Health Department
35
Community Options, Assisted Living (ALF)​
Community Options, Other​​
76
​Community Violence Prevention​
​VP
DDA Services, Provider New Enrollees
90
Dental Pro​vider Individual​
Dental Provider Group​
14
Diabetes Prevention Program (DPP) Provider
DP
Diagnosis Services, Other
60
Dialysis Facility
61
DMS/DME Provider​
62
Doula Individual​
Doula Group
DL
EPSDT Therapeutic Behavioral Services​
51
Freestanding Oncology Services
36
​​Gender Affirming Treatment - Electrologist and Medical Tattoo Artist Individual​
Gender Affirming Treatment - Electrologist and Medical Tattoo Artist​ Group
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HCBS, 1915i
89
HCBS, 1915i Individual
HCBS, 1915i Group
HG
​Healthy Steps Individual​​
Health Steps Group​​
​NA
HIV Case Management​
VC
​​HM​O/PACE​
70​
​Home Health Agency
41
Home Visiting Services
HV
​Hospice Provider​​
​71
Hospital, Acute
01
Hospital, Acute Rehabilitation​
03
Hospital, Chronic
05
Hospital, Chronic Rehabilitation
04
Hospital, Specific Other Acute
06
Hospital, Specific Other Chronic​
07
IMD Residential SUD Adult
54
Intermediate Care Facility, Addiction
55
Local Education Agencies/Local Lead Agency
91
Medical Day Care, Adults
42
Medicare Crossover Only​​
XV
Mental Health Case Management Provider​
CM
Mental Health Clinic
MC
​​Mobile Crisis Team​
​MS
Mobile Treatment Program​
MT
Nursing Facility​​​
57
​Ordering, Referring, Prescribing (ORP-only) Provider​
​92
Pain Management
N/A
Partial Hospitalization Program
MH
Pediatric Nursing/Home Health Aide Services Agency​
53
​​Pharmacist Group​
​PH
Portable X-Ray
59
Psychiatric Rehab Services Facility
PR
Residential Treatment Center
88
School Based Health Center (SBHC)
N/A
​​School Psychologist​ 
​GP
Suppo​rted Employment
SE
Urgent Care Center​​
08​



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