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Mississippi Envision :: Quality Healthcare Services Improving Lives

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
    • 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.
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 who are indicating a change of ownership, please contact a Provider Enrollment Specialist.
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.
  • ERA Enrollment Application
Thank you for your interest in supporting the Mississippi Medicaid Program. If you have any questions, please contact Xerox at (800) 884-3222.