Font Size
-
+
Employee Email   |   Envision Web Portal   |  

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
FamilyPlanningServices FamilyPlanningServices.pdf May 8, 2014 7:52 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
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
DOM_MAGIApp DOM_MAGIApp.pdf October 11, 2019 3:50 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
Rebuttal Request Form Rebuttal-Request-Form.pdf June 13, 2018 8:05 pm
Hysterectomy Acknowledgement Form Hysterectomy-Acknowledgement-Form.pdf February 14, 2019 8:17 pm
Provider Change of Address Form ProviderChangeofAddressForm.pdf June 4, 2014 7:23 pm
Sterilization Consent Form – ordered through Conduent Sterilization-Consent-Form.pdf March 11, 2019 6:13 pm
Sterilization Consent Form – electronic Electronic-Sterilization-Consent.pdf August 7, 2019 1:53 pm
Primary Care Physician Self-Attestation Form PCPSelf-AttestationForm.pdf January 14, 2015 4:14 pm
SpeakerRequest SpeakerRequest.pdf January 2, 2019 2:20 pm
Primary Care Physicians Self-Attestation General Instructions PCPSelf-AttestationGeneralInstructions.pdf January 14, 2015 4:23 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
Addendum for Nursing Facility Ventilator Dependent Care Services Form Addendum_NursingFacilityVent.pdf January 14, 2015 6:34 pm
Medical Authorization Form Request-for-Beneficiary-Access-to-Protected-Health-Information.pdf January 31, 2018 9:05 pm
Medical Supplies – Certificate of Medical Necessity (CMN) Medical-Supplies-Certificate-of-Medical-Necessity-CMN.pdf April 10, 2019 3:08 pm
Claim Reconsideration Form ClaimCheck_Reconsideration_Form.pdf April 20, 2014 7:43 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
Non-Emergency-CMN Non-Emergency-CMN.pdf September 5, 2018 2:01 pm
Provider Bulletin Subscription Request Form Provider-Bulletin-Subscription-Request-form.pdf September 12, 2017 5:10 pm
Adjustment/Void Request Form Adj-Void_rev_0306_rev.pdf April 19, 2014 3:08 pm
Part B Crossover Form 2.3-Part-B-Crossover-Instructions.pdf November 13, 2019 3:40 pm
Part A Crossover Form 3.2-Part-A-Crossover-Instructions.pdf November 13, 2019 3:40 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
Certificate of Medical Necessity (CMN) – Incontinence Supplies CMN-Incontinence-Supplies.pdf December 31, 2019 2:19 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
MississippiCAN Inquiry/Complaint Form MississippiCAN-Inquiry-Complaint-Form.pdf May 24, 2017 2:11 pm
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

Early and Periodic Screening, Diagnosis, and Treatment

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 September 9, 2019 4:10 pm


Long Term Care Cost Report Forms

Long Term Care Facility Cost Report Forms – Integrated
Title File Name Caption Date
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
Form 19: Ventilator Dependent Care Expenses Form19.xlsx April 14, 2015 9:00 pm
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
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 February 12, 2020 4:37 pm