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 |
|---|---|---|---|
| SpeakerRequest | SpeakerRequest.pdf | January 2, 2019 2:20 pm | |
| 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 | |
| Adjustment/Void Request Form | Adj-Void_rev_0306_rev.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 | February 14, 2019 8:17 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 | |
| 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 | |
| Provider Bulletin Subscription Request Form | Provider-Bulletin-Subscription-Request-form.pdf | September 12, 2017 5:10 pm | |
| Medical Authorization Form | Request-for-Beneficiary-Access-to-Protected-Health-Information.pdf | January 31, 2018 9:05 pm | |
| Rebuttal Request Form | Rebuttal-Request-Form.pdf | June 13, 2018 8:05 pm | |
| Non-Emergency-CMN | Non-Emergency-CMN.pdf | September 5, 2018 2:01 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 | March 12, 2019 3:40 pm | |
| Medical Supplies – Certificate of Medical Necessity (CMN) | Medical-Supplies-Certificate-of-Medical-Necessity-CMN.pdf | April 10, 2019 3:08 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 |
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 | 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 | 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 | |
| MississippiCAN Inquiry/Complaint Form | MississippiCAN-Inquiry-Complaint-Form.pdf | May 24, 2017 2:11 pm | |
| 2018 MississippiCAN Provider Survey | 2018-MSCAN-Provider-Survey.pdf | August 7, 2018 7:42 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 | April 20, 2017 8:49 pm |
Community Transition Services (CTS) Forms
| Title | File Name | Caption | Date |
|---|---|---|---|
| CTS Initial Referral Form | CTS.1-Initial-Referral.pdf | January 4, 2018 2:56 pm | |
| CTS Freedom of Choice Provider Selection | CTS.3-Freedom-of-Choice-Provider-Selection.pdf | January 4, 2018 2:58 pm | |
| CTS Bill of Rights | CTS.4-Bill-of-Rights.pdf | January 4, 2018 2:59 pm | |
| CTS Risk and Transition Worksheet | CTS.5-Risk-and-Transition-Worksheet.pdf | January 4, 2018 2:59 pm | |
| CTS Household Furnishings Worksheet | CTS.6-Household-Furnishings-Worksheet.pdf | January 4, 2018 3:00 pm | |
| CTS Consent to Participate | CTS.7-Consent-to-Participate.pdf | January 4, 2018 3:01 pm | |
| CTS Discharge Form | CTS.8-Discharge-Form.pdf | January 4, 2018 3:02 pm |
