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Mississippi Envision
Electronic Funds Transfer (Direct Deposit)
Please complete the following Direct Deposit Authorization/Agreement Form. A voided check or letter from the bank showing your account type, account number and routing number will need to be uploaded with this form in order for us to complete your enrollment process and begin depositing your funds electronically. Alert: If you choose not to complete this agreement you will not be assigned a Mississippi Medicaid Provider Number. You may contact Mississippi's Provider Relations Unit at 1-800-884-3222, Monday-Friday 8AM-5PM CST if you have any questions about the Direct Deposit Authorization/Agreement Form or wish to inquire upon the status of a form that has already been submitted.

It is the Provider's responsibility to contact their financial institutions to arrange for delivery of the CCD+ (addenda detail record) data elements needed for re-association of the payment and the ERA.


For further instructions please click here.
Provider Information
Provider Name*:
Provider Identifiers Information
Provider Federal Tax Identification Number (TIN)*: National Provider Identifier (NPI)*:
or Employer Identification Number (EIN)  
Provider Contact Information
Provider Contact Name:
Title :
Telephone Number : Telephone Number Extension :
Email Address :
Fax Number :
Financial Institution Information
Financial Institution Name* :
Financial Institution Address :
Street : City : State : Zip :
Financial Institution Routing Number*:
Type of Account at Financial Institution*:
Checking
Savings
Provider's Account Number with Financial Institution*:
Account Number Linkage to Provider Identifier: Provider Tax Identification Number (EIN/TIN)
(Must Match ERA Preference) National Provider Identification Number (NPI)
Submission Information
Reason for Submission*: New Enrollment
  Change Enrollment
  Cancel Enrollment
Authorized Signature
I understand that payment and satisfaction of this claim will be from federal and state funds, and that any false claims, statements, documents; or concealment of a material fact, may be prosecuted under applicable federal or state laws.I further authorize the Mississippi Division of Medicaid to present credit entries (deposits) into the bank account referenced above and depository named above. These credits will pertain only to direct deposit transfer payments for Medicaid services that the payee has rendered. I further understand that in the event my bank account information was to change, I must notify the Mississippi Division of Medicaid in order to change my bank account information immediately. I will not hold the Mississippi Division of Medicaid liable for presentation of any and all credit entries (deposits) into the bank account referenced above and the depository named above if I fail to notify the Division of Medicaid or the fiscal agent of my change in bank account information.
Printed Name of Person Submitting Enrollment *: Submission Date :
Please check the box below If you want to Upload any Documents.
You are required to upload a copy of the voided check.
 
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