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EIS Providers Enrollment & Demographic Form

This form is specific to Early Steps Intervention (EIS) providers only.

Please note: Sunshine Health leverages the Department of Health’s (DOH) Provider Master List, however, not all provider essential information is found on the PML.

The Provider Master List contains DOH-certified early intervention providers. You can download the list from the Florida Early Steps website.

Please select the AHCA Region associated with your location of service* (View a map of AHCA regions (PDF) if you’re unsure):

Please Select Region(s): required *
Please confirm the reason for request: required *
Will you be submitting claims under a group or as an individual practitioner? required *
Do you need to add another Tax ID Number? required *
Do you need to add another Tax ID Number? required *
Do you need to add another Tax ID Number? required *
Do you need to add another Tax ID Number? required *
Do you need to add another Individual NPI? required *
Do you need to add another Individual NPI? required *
Do you need to add another Individual NPI? required *
Do you need to add another Individual NPI? required *
Do you need to add another Taxonomy Code? required *
Do you need to add another Taxonomy Code? required *
Do you need to add another Taxonomy Code?
Do you need to add another Taxonomy Code? required *

Please note: We will review your request once emailed to the appropriate EIS Provider Engagement Adminstrator.. If the request is to add or update information, please allow five (5) business days to be provided with an update. Confirmation will be provided once the request is complete.

Additional Information

Questions?

Locate your assigned EIS Administrator at the Find your Provider
Engagement Administrator link.