Get Passport To Health Provider Change/enrollment Form - Medicaidprovider Hhs Mt

This guide provides a clear and supportive approach to completing the Passport To Health Provider Change/Enrollment Form for Medicaid users. Following these steps will help you successfully navigate the online form and ensure your provider change or enrollment is processed smoothly.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In the first section, enter the name, Medicaid/HMK Plus ID number, and date of birth for each person you are enrolling. You can locate the ID number on your Medicaid/HMK Plus card.
3. Select a Passport provider for each individual listed.
4. Next, provide your name, address, and a telephone number where you can be reached.
5. Indicate your relationship to the member who is changing their provider by checking all that apply, such as yourself, parent's name, guardian, or medical power of attorney.
6. In the reason for change of provider section, check the box next to the appropriate reason and elaborate if necessary. If your reason is not listed, you may select 'Other' and provide an explanation.
7. Once you have filled out all the required fields, review the form for accuracy.
8. Finally, save your changes, and if needed, download, print, or share the completed form. Mail it to Passport to Health at the specified address or fax it to the provided number.

Begin the process of updating your provider information online now.