Provider Enrollment Required Documentation
Provider Enrollment Application Instructions
Print out the Provider Enrollment Application and the Credentialing 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 Credentialing Requirements Checklist
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.
Signatures
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.
Links:
Credentialing Requirements Checklist
Provider Risk Level Information
Provider Enrollment Application
Electronic Funds Transfer (Direct Deposit Authorization Form)
Board of Directors Resolution
Medical Assistance Participation Agreement
W-9
Civil Rights Compliance Information Request for Medicaid Certification
CLIA Certification
EDI Provider Enrollment Form (Required if you intend to submit EDI)
EDI Gateway Services (Optional information about submitting EDI)
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)
ERA Enrollment Application
NF Ventilator Dependent Care Services Addendum(For Nursing Facilities Only)
Provider Disclosure Form
Thank you for your interest in supporting the Mississippi Medicaid Program. If you have any questions, please contact Conduent at (800) 884-3222.