Get Adobe ReaderA note about viewing streaming video


Provider Enrollment Forms for Specialists

All required forms for new providers (Specialists) enrolling in Missouri First Steps are listed below:

Service Provider Enrollment Checklist

Service Provider Information Form (pdf)

Service Provider Agreement (Specialist)

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

IMPORTANT:  For Assistive Technology Provider, Audiologist, Counselor, Dietician, Nurse (RN and LPN), Optometrist, Ophthalmologist, Physician, Psychologist, and Social Worker - Contact Provider Enrollment at 1-866-711-2573 (Ext. 2) for required Medicaid forms not provided above.