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Forms

Listed below are some of the most frequently used forms. You can contact the Mississippi Division of Medicaid (DOM) multiple ways as listed below, including by phone, postal mail, and fax. If you choose to contact DOM in writing, you are advised to submit information by postal mail or fax to protect the confidentiality of your protected health information or personally identifiable information.

  • Toll-free: 800-421-2408
  • Phone: 601-359-6050
  • Fax: 601-359-6294
  • Mailing address: 550 High Street, Suite 1000, Jackson, MS 39201

Eligibility Forms

Title File Name Caption Date
Application for Mississippi Medicaid Aged, Blind and Disabled DOM_ABDApp.pdf Application for Mississippi Medicaid Aged, Blind and Disabled December 16, 2013 7:27 pm
FamilyPlanningServices FamilyPlanningServices.pdf May 8, 2014 7:52 pm
DOM MAGI Application DOM_MAGIApp.pdf October 5, 2017 7:41 pm

 


Provider Forms

Title File Name Caption Date
Blood Lead Poisoning Screening Summary Blood_Lead_Poisoning_Summary.pdf April 15, 2014 9:06 pm
Abortion Abortion.pdf April 15, 2014 9:06 pm
Adolescent Counseling Adolescent-Counseling.pdf April 15, 2014 9:06 pm
Sterilization (example attached) – form must be ordered Sterilization.pdf April 15, 2014 9:17 pm
Adjustment/Void Request Form Adj-Void_rev_0306_rev.pdf April 19, 2014 3:08 pm
Rebuttal Period Request Form RebuttalRequestFormMSDOM.pdf April 19, 2014 3:08 pm
Claim Reconsideration Form ClaimCheck_Reconsideration_Form.pdf April 20, 2014 7:43 pm
Crossover Form Part B CrossOverFormPartB.pdf May 8, 2014 8:40 pm
Crossover Form Part A CrossOverFormPartA.pdf May 8, 2014 8:40 pm
Provider Change of Address Form ProviderChangeofAddressForm.pdf June 4, 2014 7:23 pm
Primary Care Physician Self-Attestation Form PCPSelf-AttestationForm.pdf January 14, 2015 4:14 pm
Primary Care Physicians Self-Attestation General Instructions PCPSelf-AttestationGeneralInstructions.pdf January 14, 2015 4:23 pm
Addendum for Nursing Facility Ventilator Dependent Care Services Form Addendum_NursingFacilityVent.pdf January 14, 2015 6:34 pm
Hysterectomy Acknowledgement Form Hysterectomy-Acknowledgement-Form.pdf November 18, 2015 10:55 pm
Federally Qualified Health Centers and Rural Health Clinics Change in Scope of Service Request Packet Provider-Change-in-Scope-of-Service-Request-Packet.pdf April 12, 2016 4:43 pm
OB/GYN Primary Care Physician Self-Attestation Form OBGYN_PCP_Self-AttestationForm.pdf May 6, 2016 3:01 pm
OB/GYN Primary Care Physician Self-Attestation General Instructions OBGYN_PCP_Self-AttestationGeneralInstructions.pdf May 6, 2016 3:04 pm
EPSDT School Health Related Provider Agreement (Only schools applying for Expanded Health Services that employ active Medicaid Physical, Occupational and Speech Therapists should complete this agreement) EPSDT-School-Health-Related-Provider-Agreement-Only-schools-applying-for-Expanded-Health-Services-that-employ-active-Medicaid-Physical-Occupational-and-Speech-Therapists-should-complete-this-agreement.pdf April 21, 2017 8:21 pm
Medical Supplies – Certificate of Medical Necessity (CMN) MedicalSuppliesCMNForm.pdf June 29, 2017 6:52 pm

 


Pharmacy Forms

Title File Name Caption Date
MedWatch Form MedWatch-Form.pdf April 8, 2014 8:47 pm
Pharmacy Notification of Other Insurance Coverage Pharmacy-Notification-of-Other-Insurance-Coverage.pdf April 8, 2014 8:48 pm
Crossover Form B CrossoverFormB.pdf April 8, 2014 8:48 pm
Pharmacy Claim Form and Form Instructions MedicaidTitleXIXPharmacyInvoice.pdf April 8, 2014 8:48 pm
Pharmacy Reconsideration Request Form Pharmacy-Reconsideration-Request-Form.pdf May 26, 2017 3:23 pm
Pharmacy Prior Authorization

 


Coordinated Care – MississippiCAN and Children’s Health Insurance Program (CHIP) Forms

Title File Name Caption Date
2014 MississippiCAN Provider Survey 2014MSCANProviderSurvey.pdf October 8, 2014 4:05 pm
CHIP Change of Plan Form for Mandatory Groups CHIP-Change-of-Plan-Form-for-Mandatory-Groups.pdf June 16, 2015 10:05 pm
CHIP Enrollment Form CHIP-Enrollment-Form.pdf June 16, 2015 10:06 pm
MississippiCAN Enrollment Form for Optional Groups MississippiCAN-Enrollment-Form-for-Optional-Groups.pdf June 16, 2015 10:06 pm
MississippiCAN Enrollment Form for Mandatory Groups MississippiCAN-Enrollment-Form-for-Mandatory-Groups.pdf June 16, 2015 10:06 pm
MississippiCAN Change of Plan Form for Optional Groups MississippiCAN-Change-of-Plan-Form-for-Optional-Groups.pdf June 16, 2015 10:06 pm
MississippiCAN Change of Plan Form for Mandatory Groups MississippiCAN-Change-of-Plan-Form-for-Mandatory-Groups.pdf June 16, 2015 10:06 pm
MississippiCAN Inquiry/Complaint Form MississippiCAN-Inquiry-Complaint-Form.pdf May 24, 2017 2:11 pm

 


Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Title File Name Caption Date
Blood Lead Poisoning Screening Summary Blood_Lead_Poisoning_Summary.pdf April 15, 2014 9:06 pm
3-5 Days EPSDT Visit Form 3-5-Days-EPSDT-Visit-Form.pdf August 12, 2016 3:08 pm
0-9 Months EPSDT Visit Form 0-9-Months-EPSDT-Visit-Form.pdf August 12, 2016 3:09 pm
1-4 Years EPSDT Visit Form 1-4-Years-EPSDT-Visit-Form.pdf August 12, 2016 3:10 pm
5-10 Years EPSDT Visit Form 5-10-Years-EPSDT-Visit-Form.pdf August 12, 2016 3:11 pm
11-21 Years EPSDT Visit Form 11-21-Years-EPSDT-Visit-Form.pdf August 12, 2016 3:11 pm
EPSDT Provider Agreement EPSDT-Provider-Agreement.pdf April 20, 2017 8:49 pm

 


Bridge to Independence Forms

Title File Name Caption Date
B2I Initial Referral Form B2I-_InitialReferralApp.pdf B2I Initial Referral Form December 13, 2013 9:36 pm
B2I Consent to Participate B2I_ConsentParticipate.pdf B2I Consent to Participate December 13, 2013 9:41 pm
B2I Surrogacy Verification B2I_SurrogacyVerification.pdf B2I Surrogacy Verification December 13, 2013 9:43 pm
B2I Bill of Rights B2I_BillRights.pdf B2I Bill of Rights December 13, 2013 9:44 pm
B2I Discharge B2I_Discharge.pdf B2I Discharge December 13, 2013 9:45 pm
B2I Household Goods and Furnishings Worksheet B2I_HouseholdWorksheet.pdf B2I Household Goods and Furnishings Worksheet December 13, 2013 9:46 pm

 


Long Term Care Cost Report Forms

Long Term Care Facility Cost Report Forms – Integrated

Title File Name Caption Date
Checklist Checklist.xlsx May 12, 2014 1:31 pm
Form 1: General information Form1.xlsx May 12, 2014 1:34 pm
Form 2: Certification by officer or administrator of provider Form2.xlsx May 12, 2014 1:34 pm
Form 3: Statistical data Form3.xlsx May 12, 2014 1:34 pm
Form 4: Patient day statistics Form4.xlsx May 12, 2014 1:34 pm
Form 5: Statement of revenues and expenses Form5.xlsx May 12, 2014 1:35 pm
Form 6: Schedule of expenses Form6.xlsx May 12, 2014 1:36 pm
Form 7: Schedule of fixed assets and depreciation (1 of 2) Form7.xlsx May 12, 2014 1:37 pm
Form 7: Schedule of fixed assets and depreciation (2 of 2) Form7-2.xlsx May 12, 2014 1:37 pm
Form 8: Facility transactions with related organizations Form8.xlsx May 12, 2014 1:37 pm
Form 9: Rental of vehicles and property Form9.xlsx May 12, 2014 1:38 pm
Form 10: Analysis of interest bearing debt and related interest expense Form10.xlsx May 12, 2014 1:38 pm
Form 11: Balance sheet Form11.xlsx May 12, 2014 1:38 pm
Form 12: Capital reconciliation Form12.xlsx May 12, 2014 1:39 pm
Form 13: Computation of return on equity Form13.xlsx May 12, 2014 1:39 pm
Form 14: Computation of per diem cost for facilities with less than 80% occupancy Form14.xlsx May 12, 2014 1:39 pm
Form 15: Owners, officers and directors compensation Form15.xlsx May 12, 2014 1:40 pm
Form 16: Disclosure of ownership Form16.xlsx May 12, 2014 2:19 pm
Form 17: Home office or related management company cost report expense allocation summary Form17.xlsx May 12, 2014 2:19 pm
Form 18: Computation of return on equity for home office Form18.xlsx May 12, 2014 2:20 pm
Schedule 1: Other income Schedule-501_1-eff.-05272010.xlsx May 12, 2014 2:20 pm
Schedule 2: Direct care allocated costs – hospital based and state facilities Schedule-501_2.xlsx May 12, 2014 2:21 pm
Schedule 3: Therapy allocated costs – hospital based and state facilities Schedule-501_3.xlsx May 12, 2014 2:21 pm
Schedule 4: Care related allocated costs – hospital based and state facilities Schedule-501_4.xlsx May 12, 2014 2:21 pm
Schedule 5: Miscellaneous Schedule-501_5.xlsx May 12, 2014 2:22 pm
Schedule 6: Administrative and operating allocated costs – hospital based and state facilities Schedule-501_6.xlsx May 12, 2014 2:22 pm
Schedule 7: Property and equipment allocated costs – hospital based and state facilities Schedule-501_7.xlsx May 12, 2014 2:22 pm
Schedule 8: Other non-allowable costs Schedule-501_8.xlsx May 12, 2014 2:22 pm
Schedule 9: Form 6 cost variances Schedule-501_9.xlsx May 12, 2014 2:23 pm
Schedule 10: Deposits Schedule-501_10.xlsx May 12, 2014 2:23 pm
Schedule 11: Home office/related management company other income Schedule-501_11.xlsx May 12, 2014 2:23 pm
Schedule 12: Home office/related management company other expense Schedule-501_12.xlsx May 12, 2014 2:23 pm
Form 19: Ventilator Dependent Care Expenses Form19.xlsx April 14, 2015 9:00 pm
Schedule 13: Employee Benefits Allocation – Hospital Based & State Facilities Schedule-501_13.xlsx February 18, 2016 7:53 pm
Schedule 14: Apportionment of Care Related Allocated Costs – Hospital Based And State Facilities Schedule-501_14.xlsx February 18, 2016 7:54 pm
Schedule 15: Apportionment Of Administrative And Operating Allocated Costs – Hospital Based And State Facilities Schedule-501_15.xlsx February 18, 2016 7:54 pm
Schedule 16: Apportionment Of Capital Allocated Costs – Hospital Based and State Facilities ( Supplement to Schedule 7) Schedule-501_16.xlsx February 18, 2016 7:55 pm
Schedule 17: Apportionment of Raw Food Costs – Hospital Based And State Facilities (Form 6, Line 3-20) Schedule-501_17.xlsx February 18, 2016 7:55 pm
Schedule 13A: Employee benefits allocation – hospital based and state facilities Schedule-501_13A.xlsx April 6, 2016 9:51 pm
Cost Report Instructions CostReportInstructions.pdf April 6, 2016 9:51 pm