MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit
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Transcript of MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit
MO HealthNet Division 1
MO HealthNet Internet Provider Training Program
Presented by the Provider Education UnitMO HealthNet Division
MO HealthNet Division 2
Proper Completion of the Medical Referral Form of Restricted
ParticipantsAlso Known as PI-118 Form
Presented by the Provider Education Unit
MO HealthNet Division
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If a provider feels that a participant is
improperly using benefits, the provider is
requested to notify the MO HealthNet
Division, Program Integrity Unit, P.O. Box
6500, Jefferson City, MO 65102 or you may
contact the Program Integrity Unit at 573-
751-3399.
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MO HealthNet ID Number
Name of Participant
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Authorized (Lock-in) Provider Name
MO HealthNet Provider Identifier
Provider Taxonomy Code
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Signature of Authorized (Lock-in) Provider
Date (Month/Day/Year)
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Date of Service (Month/Day/Year)
Reason For Referral
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Referring To Provider
Provider Address Provider Phone Number
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Provider Vendor (NPI) Number
Provider Taxonomy Code
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Obtaining a Copy of the Paper Form
To Obtain a paper copy of the form, go to
the MHD public Web site,
www.dss.mo.gov/mhd/providers/index.htm. In
the left hand column, click on “MO HealthNet
Forms”. Then scroll down the list and click on
“Medical Referral Form of Restricted
Participants (PI-118)”. You can print the form
once it opens up on your computer screen.
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Thank you again for participating in this
training program. If you have questions
regarding the information in this
presentation, please contact the Provider
Education Unit at 573-751-6683.