Get (epsdt) Program Provider Agreement Form - Mississippi Division Of ... - Medicaid Ms

Filling out the (EPSDT) Program Provider Agreement Form is an essential step for providers participating in Mississippi's Medicaid program. This guide offers a clear, step-by-step approach to help users complete the form online effectively.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the (EPSDT) Program Provider Agreement Form and open it for editing.
2. Begin by filling in your printed name in the designated area. Ensure that this is the name of the provider overseeing the screenings.
3. Enter your Division of Medicaid (DOM) provider number. This number is essential for identification and processing within the Medicaid system.
4. Indicate the physical street address where the screenings will be conducted. It is vital that this address is accurate to avoid any miscommunication.
5. Provide a telephone number where you can be reached for any follow-up or questions regarding the agreement.
6. Complete the city, state, and zip code fields corresponding to the address indicated in the previous step.
7. Enter your Clinical Laboratory Improvement Amendments (CLIA) number. This is required if you will be conducting laboratory tests.
8. Ensure you provide your original signature in the designated space. This confirms your agreement to adhere to the practices outlined in the form.
9. If applicable, provide the name of your group affiliation for screening purposes, along with the group DOM provider number.
10. After completing all fields, review the entire form for accuracy before proceeding to save, download, or print your completed document.

Complete your (EPSDT) Program Provider Agreement Form online today to ensure timely participation and compliance.