Maine DHHS Provider Portal

New Admit For MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
* = Required Field

Member Information
First Name:	* Required Field *
Middle Name:
Last Name:	* Required Field *
MaineCare #: (12345678A or 12345678T)	12345678A or 12345678T * Required Field *
Facility/Agency Information
Facility Name:	Type your facility name only if it is not in the drop-down list.
Phone: (xxx-xxx-xxxx)	* Invalid phone number * Required Field *
Fax: (xxx-xxx-xxxx)	* Invalid fax number *
Contact Name:	* Required Field *
E-Mail:	* Invalid e-mail address *
Admission Information
Admit Date: (mm/dd/yyyy on or before today's date)	* Required Field Invalid date: use mm/dd/yyyy Must be on or before 11/8/2024 *
Is this a transfer from another nursing facility? Yes (Facility Name) * Required
Special Notes

Submission Authorization:
Access Code:	* Access Code is Required *

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Aging & Disability Services