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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_MAGIApp DOM_MAGIApp.pdf October 11, 2019 3:50 pm
DOM-317 Form – Exchange of Information Between Long Term Care Facility and Regional Medicaid Office DOM-317-Form.pdf January 28, 2020 6:45 pm
53939_MAGI Application_Spanish 53939_MAGI-Application_Spanish.pdf April 5, 2024 9:33 pm
53939_ABD Application_Spanish 53939_ABD-Application_Spanish.pdf April 5, 2024 9:37 pm

Provider Enrollment Forms

Title File Name Caption Date
Civil Rights Compliance Information Request for Medicaid Certification Civil-Rights-Compliance-Information-Request-for-Medicaid-Certification.pdf May 10, 2022 3:19 pm
Provider Disclosure Form Provider-Disclosure-Form.pdf May 10, 2022 3:40 pm
Provider Risk Level Information Provider-Risk-Level-Information.pdf May 10, 2022 3:42 pm
W-9 W-9.pdf May 10, 2022 3:43 pm
NF Ventilator Dependent Care Services Addendum (For Nursing Facilities Only) NF-Ventilator-Dependent-Care-Services-Addendum-For-Nursing-Facilities-Only.pdf May 10, 2022 3:43 pm
Provider Application Cover Letter (For Out of State Providers Only) Provider-Application-Cover-Letter-For-Out-of-State-Providers-Only.pdf May 10, 2022 3:44 pm
Medical Assistance Participation Agreement Medical-Assistance-Participation-Agreement.pdf October 3, 2022 1:26 am
Electronic Funds Transfer (Direct Deposit Authorization Form) Electronic-Funds-Transfer-Direct-Deposit-Authorization-Form.docx October 10, 2022 7:34 pm
Additional Enrollment Requirements Checklist MS-Checklist-04252023-v2.xlsx April 25, 2023 8:06 pm

Provider Forms

Title File Name Caption Date
Certificate of Medical Necessity (CMN) – Incontinence Supplies CMN-Incontinence-Supplies.pdf December 31, 2019 2:19 pm
PCP Self-Attestation Fillable Form PCP-Self-Attestation-Fillable-Form.pdf June 13, 2024 6:22 pm
Lead Risk Screening Questionnaire Lead-Risk-Screening-Questionnaire.pdf June 4, 2024 5:38 pm
DOM 260 – ICF IID Pre-Admission Form DOM-260-ICF-IID-Pre-Admission-Form.pdf April 16, 2024 7:02 pm
Gender Reassignment Form Gender-Reassignment-Form.pdf January 12, 2024 3:47 pm
Claim Attachment Form Claim-Attachment-Form.pdf December 9, 2022 4:36 pm
Provider Change of Address Form Provider-Change-of-Address-Form.docx October 10, 2022 7:13 pm
Medical Assistance Participation Agreement Medical-Assistance-Participation-Agreement.pdf October 3, 2022 1:26 am
Sterilization Consent Form_Spanish (español) – PDF Sterilization-Consent-Form_Spanish-espanol-PDF.pdf September 20, 2022 4:07 pm
Sterilization Consent Form_English – PDF Sterilization-Consent-Form_English-PDF.pdf September 20, 2022 4:03 pm
Private Duty Nursing Provider Enrollment Packet PDN-provider-enrollment-packet_FINAL-v4.pdf July 1, 2020 9:17 pm
Appointment of Authorized Representative form – Eff. April 1, 2020 Appointment-of-Authorized-Representative-Form-Section-9.2-Billing-Manual.pdf January 22, 2020 9:10 pm
SpeakerRequest SpeakerRequest.pdf January 2, 2019 2:20 pm
Medical Supplies – Certificate of Medical Necessity (CMN) Medical-Supplies-Certificate-of-Medical-Necessity-CMN.pdf April 10, 2019 3:08 pm
Non-Emergency-CMN Non-Emergency-CMN.pdf September 5, 2018 2:01 pm
Rebuttal Request Form Rebuttal-Request-Form.pdf June 13, 2018 8:05 pm
Medical Authorization Form Request-for-Beneficiary-Access-to-Protected-Health-Information.pdf January 31, 2018 9:05 pm
Provider Bulletin Subscription Request Form Provider-Bulletin-Subscription-Request-form.pdf September 12, 2017 5:10 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
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
Hysterectomy Acknowledgement Form Hysterectomy-Acknowledgement-Form.pdf February 14, 2019 8:17 pm
Addendum for Nursing Facility Ventilator Dependent Care Services Form Addendum_NursingFacilityVent.pdf January 14, 2015 6:34 pm
Adolescent Counseling Adolescent-Counseling.pdf April 15, 2014 9:06 pm
Abortion Abortion.pdf April 15, 2014 9:06 pm
Hospice Forms

Pharmacy Forms

Title File Name Caption Date
MedWatch Form MedWatch-Form.pdf April 8, 2014 8:47 pm
Pharmacy-Notification-of-Other-Insurance-Coverage.pdf Pharmacy-Notification-of-Other-Insurance-Coverage.pdf August 15, 2019 4:23 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 Prior Authorization

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

Title File Name Caption Date
CHIP-Change-of-Plan-Form-for-Mandatory-Groups CHIP-Change-of-Plan-Form-for-Mandatory-Groups.pdf September 9, 2019 8:55 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 August 7, 2018 7:46 pm
MississippiCAN Enrollment Form for Mandatory Groups MississippiCAN-Enrollment-Form-for-Mandatory-Groups.pdf August 7, 2018 7:47 pm
MississippiCAN Change of Plan Form for Optional Groups MississippiCAN-Change-of-Plan-Form-for-Optional-Groups.pdf August 7, 2018 7:52 pm
MississippiCAN Change of Plan Form for Mandatory Groups MississippiCAN-Change-of-Plan-Form-for-Mandatory-Groups.pdf August 7, 2018 7:50 pm
2019 MississippiCAN Provider Survey Provider-Survey-2019.pdf August 26, 2019 5:43 pm
2020 Provider Workshop Webinar 2020-Provider-Workshop-Webinar.pdf October 21, 2020 9:45 pm
MississippiCAN Comparison Chart MississippiCAN-Comparison-Chart.pdf October 4, 2022 8:03 pm
CHIP Comparison Chart CHIP-Comparison-Chart.pdf October 4, 2022 8:03 pm
Managed Care Provider Inquiries & Issues Form

Early and Periodic Screening, Diagnosis, and Treatment

Title File Name Caption Date
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
EPSDT Provider Agreement 082020 EPSDT-Provider-Agreement-082020.pdf August 7, 2020 10:14 pm
11-20 Years EPSDT Visit Form 11-20-Years-EPSDT-Visit-Form.pdf October 27, 2023 4:09 pm
Lead Risk Screening Questionnaire Lead-Risk-Screening-Questionnaire.pdf June 4, 2024 5:38 pm


Long Term Care Cost Report Forms

Title File Name Caption Date
LTCF-Cost-Report-Forms-Integrated_1.1.2022 LTCF-Cost-Report-Forms-Integrated_1.1.2022.xlsx December 20, 2021 10:12 pm
LTCF-Cost-Report-2022-Year-Ends-Only LTCF-Cost-Report-2022-Year-Ends-Only.xlsx October 13, 2022 2:37 pm
Cost Report Instructions Cost-Report-Instructions.pdf May 8, 2023 10:04 pm
Cost Report Instructions 2023 – Reports Filed After 09.30.2023 Cost-Report-Instructions-2023-Reports-Filed-After-09.30.2023.rtf September 25, 2023 7:18 pm
LTCF – Cost Report Forms Integrated 2023 – Reports Filed After 09.30.2023 LTCF-–-Cost-Report-Forms-Integrated-2023-–-Reports-Filed-After-09.30.2023.xlsx March 25, 2024 9:40 pm