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Enrollment Forms for Providers Requiring Supervision

All required forms for new providers requiring supervision and enrolling in Missouri First Steps are listed below:

Service Provider Enrollment Checklist

Service Provider Information Form (pdf)

Service Provider Agreement (Supervision Required)

Background and Fingerprinting Check Procedures

Scheduling a Fingerprinting Appointment

Family Care Safety Registry

Lobbying, Debarment, Suspension Form

Medicaid/Medicare Provider Information

Certification for Online Claims

Electronic Signature

User Online Access Request Form (pdf and fill-form)

User Access Description

W-9

 

EFT/Direct Deposit Authorization