How can I become a provider for Medicaid and MIP?

Please contact the Bureau of Health Care and Financing Administration office located at the Castle Mall in Mangilao, Monday to Friday, 8:00am to 5:00pm, Closed on the weekends and GovGuam Holidays and ask for Annabelle Estrada at Tel. 735-7472 Email: annabelle.estrada@dphss.guam.gov or Teresita Guamataotao at Tel. 735-7470 Email: teresita.gumataotao@dphss.guam.gov.

What are the requirement to become a provider?

Get started by printing and filling out the Provider Application and Agreement Form in legal form (8.5. x 14) and providing the following required documents and information:
  • Provider Application and Agreement (PAA) form in legal form (8.5.x14). Download here.
  • PPA must include start date for each provider name listed on the agreement form.
  • Vendor Electronic Funds Transfer (EFT) Authorization form. Download here.
  • Vendor Record form. Download here.
  • Copy of Guam Business License/Certificate of Exemption
  • Employer Identification Number (EIN)
  • Tax Identification Number (TIN)
  • Copy of current Professional License/Certificates indicated on PAA.
  • Certification Information (Curriculum Vitae, Diploma, National Provider information (NPI), Drug Enforcement Administration (DEA), Control Substances Registration (CSR), Business Associate Agreement (BAA)).
  • Medicare Approval/Certificate (if applicable)
  • Provide three (3) authorized full name for the release of Explanation of Benefits (EOB).
  • The original Provider Application and Agreement (PPA) along with the above required documents and information must be mailed or delivered to DPHSS Bureau of Health Care Financing Administration address below:

    DPHSS Bureau of Health Care Financing Administration

    123 Chalan Kareta

    Mangilao, Guam 96913-6304

    Telephone Number: (671) 735-7255/302/225/249/293

    Fax Number: (671) 734-6860 / 735-7270

    How do I submit my claims?

    There are several way to submit your claims for payment.
  • Electronic submission via clearing house – System Interface
  • Online submission via U-Log – Claims Self Data Entry
  • Paper submission to DPHSS via hand-delivery
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