Publication Date |
File |
File Size |
File Type |
12/04/2019 |
Medicaid to Schools Enrollment Questions
|
2550k |
PDF |
12/04/2019 |
Medicaid to Schools Enrollment Presentation
|
3198k |
PDF |
4/23/2020 |
Medicaid to Schools OPLC Guidance 2020
|
5531k |
PDF |
01/01/2022 |
Carrier ID
|
563k |
PDF |
10/27/2021 |
W-9
|
|
|
04/01/2020 |
NH Medicaid Provider Participation Agreement (PPA)
|
538k |
PDF |
03/03/2023 |
NH Medicaid Dental Enrollment Acknowledgement Form
|
81k |
PDF |
08/01/2018 |
Authorized Representative Appointment or Removal Form
|
258k |
PDF |
08/01/2018 |
Managing/Directing Employee Appointment or Removal Form
|
259k |
PDF |
06/01/2020 |
Required Enrollment Documents to Upload with New Applications
|
506k |
PDF |
02/13/2018 |
Enrollment Toolkit (UNDER CONSTRUCTION)
|
88k |
PDF |
03/03/2018 |
Billing Agent Agreement (Individual)
|
32k |
PDF |
07/12/2015 |
Electronic Remittance Advice Enrollment Application
|
369k |
PDF |
07/12/2015 |
Electronic Remittance Advice Enrollment Instructions
|
248k |
PDF |
07/12/2015 |
Electronic Funds Transfer Enrollment Application
|
392k |
PDF |
07/12/2015 |
Electronic Funds Transfer Enrollment Instructions
|
269k |
PDF |
07/12/2015 |
Electronic Funds Transfer Enrollment Agreement
|
107k |
PDF |
09/21/2017 |
NH MMIS Health Enterprise Portal Registration Form
|
73k |
PDF |
03/02/2018 |
Change of Information Form
|
43k |
PDF |
02/15/2019 |
Enrollment/Revalidation Signature Page
|
112k |
PDF |
05/18/2018 |
Trading Partner Agreement Signature Page
|
70k |
PDF |
05/18/2018 |
Instructions for Individual Enrollment Application
|
1913k |
PDF |
05/18/2018 |
Instructions for Group Enrollment Application
|
2139k |
PDF |
05/18/2018 |
Instructions for Facility Provider Enrollment Application
|
2213k |
PDF |
05/18/2018 |
Instructions for Trading Partner Enrollment Application
|
1125k |
PDF |
03/28/2018 |
Paperwork Attachment Cover Sheet
|
36k |
DOC |
03/28/2018 |
Adjustment Form Conduent
|
36k |
DOC |
03/28/2018 |
Medicare Crossover Form
|
36k |
DOC |
12/01/2018 |
Form 282A - Medicaid Hospice Care Notification Form Election, change in Designated Hospice, Revocation, Death
|
16k |
PDF |
01/22/2013 |
FORM 282B - SERVICE UTILIZATION WITHIN HOSPICE BY RECIPIENT
|
17k |
XLS |
01/22/2013 |
FORM 286 - REQUEST FOR INCONTINENCE PRODUCT NOT ON PRODUCT OFFERING SHEET
|
102k |
PDF |
01/22/2013 |
INSTRUCTIONS FOR FORM 904
|
17k |
PDF |
01/22/2013 |
FORM 904 - CERTIFICATION OF THE DECISION TO TERMINATE PREGNANCY
|
20k |
PDF |
03/28/2018 |
FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA
|
65k |
PDF |
03/28/2018 |
FORM 910 - ACKNOWLEDGMENT OF STERILIZATION AS A RESULT OF HYSTERECTOMY
|
65k |
PDF |
01/22/2013 |
"NO USAR" FORMULARIO DE 910 - NOTIFICACIÓN DE ESTERILIZACIÓN COMO RESULTADO DE UNA HISTERECTOMÍA
|
16k |
PDF |
03/28/2018 |
INSTRUCTIONS FORM HHS 687i - CONSENT FOR STERILIZATION
|
299k |
PDF |
01/25/2018 |
FORM HHS 687 - CONSENT FOR STERILIZATION
|
137k |
PDF |
02/12/2013 |
FORMULARIO DE HHS 687-1 - CONSENTIMIENTO PARA LA ESTERILIZACIÓN
|
504k |
PDF |
03/28/2018 |
FORM 957X - OVERRIDE REQUEST
|
31k |
PDF |
10/01/2014 |
NH Medicaid Non-Primary Claim Billing Requirements
|
110k |
PDF |
03/08/2015 |
Interpreter Provider Billing Guidelines
|
100k |
PDF |
03/08/2015 |
Revised Vaccine and Immunization Administration Billing Guidelines
|
82k |
DOC |