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 Enrollment Forms
| Title | File Name | Caption | Date |
|---|---|---|---|
| Provider Enrollment Application Packet | Provider-Enrollment-Application-Packet.pdf | May 10, 2022 3:10 pm | |
| Additional Enrollment Requirements Checklist | Additional-Enrollment-Requirements-Checklist.pdf | May 10, 2022 3:18 pm | |
| Civil Rights Compliance Information Request for Medicaid Certification | Civil-Rights-Compliance-Information-Request-for-Medicaid-Certification.pdf | May 10, 2022 3:19 pm | |
| ERA Enrollment Application | ERA-Enrollment-Application.pdf | May 10, 2022 3:36 pm | |
| Electronic Funds Transfer (Direct Deposit Authorization Form) | Electronic-Funds-Transfer-Direct-Deposit-Authorization-Form.pdf | May 10, 2022 3:39 pm | |
| Medical Assistance Participation Agreement | Medical-Assistance-Participation-Agreement.pdf | May 10, 2022 3:40 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 |
EDI Provider Enrollment Form
EDI Trading Partner and Business Associate Agreement
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 | |
| Private Duty Nursing Provider Enrollment Packet | PDN-provider-enrollment-packet_FINAL-v4.pdf | July 1, 2020 9:17 pm | |
| SpeakerRequest | SpeakerRequest.pdf | January 2, 2019 2:20 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 | |
| 2021 PCP Self-Attestation Fillable Form | 2021-PCP-Self-Attestation-Fillable-Form.pdf | May 5, 2021 9:38 pm | |
| 2021 PCP Payment General Instructions | 2021-PCP-Payment-General-Instructions_letter.pdf | May 5, 2021 9:44 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 |
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 |
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 |
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 | |
| EPSDT Provider Agreement 082020 | EPSDT-Provider-Agreement-082020.pdf | August 7, 2020 10:14 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 |
Long Term Care Cost Report Forms
| Title | File Name | Caption | Date |
|---|---|---|---|
| Cost Report Instructions | Instructions-2020-revision-6.24.20.pdf | November 3, 2020 4:47 pm | |
| LTCF-Cost-Report-Forms-Integrated_1.1.2022 | LTCF-Cost-Report-Forms-Integrated_1.1.2022.xlsx | December 20, 2021 10:12 pm |
