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Mississippi Envision :: Quality Healthcare Services Improving Lives

Provider Enrollment Required Documentation
Provider Enrollment Application Instructions
New policy concerning Out of State enrollment and Effective Date of Provider Agreement is located in the Division of Medicaid's Admin Code Title 23, Part 200, Chapter 4, Rule 4.2 (B) and Rule 4.4 located at
  • Print out the Provider Enrollment Application and the Additional Enrollment Requirements Checklist forms from the list of links given below.
  • All enrolling providers are required to submit:
    • A completed Mississippi Medicaid Enrollment Application
    • A completed Mississippi Medicaid Provider Disclosure Form
    • Electronic Funds Transfer (Direct Deposit Authorization Form) including verification of the bank account (preprinted voided check, deposit slip or letter from the bank verifying the account number and transit routing number
    • Medical Assistance Participation Agreement
    • Completed W-9 for the enrolling provider
    • Completed Civil Rights Compliance Information Request Package
    • Any additional specific required documentation for the provider type in which you are enrolling as noted on the Additional Enrollment Requirements Checklist
    • Effective from 01/01/2020, all Out of State enrolling providers are also required to submit the Provider Application Cover Letter
  • After verifying your specific required documentation and completing the necessary forms, mail the signed signature page and all other required documents to:

    Mississippi Medicaid Program
    Provider Enrollment
    P.O. Box 23078
    Jackson, MS 39225
  • Retain a copy of the completed application for your records.
This application will not be accepted if any portion has been filled out incorrectly, form(s) are not completed and/or missing.
Original signatures are required on the signature page. Copied or stamped signatures are not acceptable. Correction fluid is not permissible on any portion of this application including signature pages.
Contact a Provider Enrollment Specialist
You may contact a Provider Enrollment Specialist by calling (800) 884-3222 for any questions concerning this application.
Change of Ownership Applicants
All applicants indicating a Change of Ownership: A Provider Enrollment Application must be submitted (see Links below). If you have questions, contact a Provider Enrollment Specialist at (800) 884-3222.
PDF Files
PDF Files are used throughout the application as a file type for additional information documents. To view PDF files
you will need Adobe Acrobat Reader installed on your machine. For a free download please click the Acrobat Reader icon.
Thank you for your interest in supporting the Mississippi Medicaid Program. If you have any questions, please contact Conduent at (800) 884-3222.