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Get Ms Dom-1165-a 2011-2026
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How to fill out the MS DOM-1165-A online
This guide provides comprehensive instructions on how to effectively fill out the Election Statement Form MS DOM-1165-A online. Follow the steps carefully to ensure accurate completion of this essential document for hospice services.
Follow the steps to complete the form successfully.
- Click the ‘Get Form’ button to retrieve the form and open it for editing.
- In the 'Beneficiary Name' field, enter the individual's name exactly as it appears on their Medicaid card.
- Fill in the 'Beneficiary Medicaid Number' precisely as shown on their Medicaid card.
- Complete the address section by providing the beneficiary's street address, city, state, and zip code.
- If applicable, fill in the 'Beneficiary/Legal Guardian/Representative’s Signature' field.
- Ensure the 'Provider Signature' is present; this is mandatory.
- Enter the provider's name in the designated field.
- Complete the 'Medicaid Provider Number/NPI Number' section by providing the appropriate information.
- Review all filled sections to confirm the accuracy of information provided.
- After ensuring everything is filled out correctly, save your changes. You can download, print, or share the completed form as needed.
Complete your forms online today to ensure timely processing and access to hospice services.
To enroll as a Medicaid provider in Mississippi, you need to fill out the application and submit it, including the MS DOM-1165-A. It is essential to follow all the stated guidelines and provide the necessary documentation to avoid delays. After submitting your application, stay in touch with the Medicaid office for updates, ensuring a smooth enrollment process.
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