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Extension of deadline to submit EPSDT Provider Agreement

Effective November 1, 2015, Mississippi Division of Medicaid (DOM) received Centers for Medicare and Medicaid Services (CMS) approval of State Plan Amendment (SPA) 15-017 Early and Periodic Screening, Diagnosis and Treatment (EPSDT).  SPA 15-017 requires DOM EPDST providers adhere to the American Academy of Pediatrics Bright Futures periodicity schedule for physical, mental, psychosocial and/or behavioral health, vision, hearing, adolescent, and developmental screening services.

EPSDT screening providers, currently enrolled in the program, must update their enrollment status by completing the EPSDT Provider Agreement.  The EPSDT Provider Agreement is located on the DOM website at https://medicaid.ms.gov/resources/forms/.  Providers must send the completed and signed EPSDT Provider Agreement by November 30, 2016 to:

Division of Medicaid-Office of Medical Services
550 High Street, Suite 1000, Jackson, MS 39202
or via fax to (601) 359-6147

Failure to send the completed and signed EPSDT Provider Agreement by November 30, 2016 may result in provider disenrollment from the EPSDT program.

Instructions for completing the EPSDT Provider Agreement:

  • All requested information on the agreement must be completed.
  • Incomplete agreements will not be processed.
  • The provider must sign and date the form.

Please contact the Office of Medical Services at (601) 359-6150 if you have any questions or need additional assistance.

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