№ lp_1_2_51194
Administrative form instructions issued by a state Medicaid agency describing required information, submission methods, and legal attestation for providers requesting updates to address records in the Mississippi Medicaid enrollment system.
Year: 2022
Region / State: Mississippi, United States
Program: Mississippi Medicaid
Document type: Administrative form instructions and declaration
Issuing body: Mississippi Medicaid Provider Enrollment
Subject: Provider change of address
Applicable entities: Individual providers, group providers, facilities, other provider types
Required signatures: Individual provider or authorized representative
Submission methods: Mail, fax
Mailing address: P.O. Box 23078, Jackson, MS 39225
Fax number: 866-644-6148
Contact phone: (800) 884-3222
Legal basis: Declaration under penalty of perjury under the laws of the State of Mississippi
Revision date: October 10, 2022
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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