Provider Enrollment Forms

All forms needed for the following First Steps provider types:

• Specialist
• Providers Requiring Supervision
• Parents/Family Members
• Service Coordinator

Specialists 

Includes: ABA Consultant, Assistive Technology Provider, Audiologist, Counselor, Dietician, Interpreter, Nurse (RN and LPN), Occupational Therapist, Optometrist, Ophthalmologist, Orientation and Mobility Specialist, Physical Therapist, Physician, Psychologist, Special Instructor, Speech/Language Pathologist, Social Worker, Translator, and Transportation Provider

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

• Service Provider Enrollment Checklist
• Service Provider Information Form
• Service Provider Agreement (Specialist)
• Complete a Fingerprint/Background Check 
  • Applicant’s Privacy Rights
  • Scheduling a Fingerprinting Appointment The four digit registration number for First Steps applicants is 2298. 
  • FAQ for Fingerprinting/Background Check Procedures 
• Family Care Safety Registry
• Lobbying, Debarment, Suspension Form
• Medicaid/Medicare Provider Information
• Certification for Online Claims
• Electronic Signature
• User Online Access Request 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.

Providers Requiring Supervision

Includes: ABA Implementer, Occupational Therapy Assistant (COTA), Paraprofessional, Physical Therapist Assistant (PTA), and Speech/Language Pathology Assistant (SLPA)

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 
• Service Provider Agreement (Supervision Required)
• Complete a Fingerprint/Background Check 
  • Applicant’s Privacy Rights
  • Scheduling a Fingerprinting Appointment The four digit registration number for First Steps applicants is 2298. 
  • FAQ for Fingerprinting/Background Check Procedures
• Family Care Safety Registry
• Lobbying, Debarment, Suspension Form
• Medicaid/Medicare Provider Information
• Certification for Online Claims
• Electronic Signature
• User Online Access Request Form  
• User Access Description
• W-9
• EFT/Direct Deposit Authorization

Parents/Family Members

All required forms for new family members who enroll in Missouri First Steps to provide transportation are listed below:

• Family Member Transportation Enrollment Checklist
• Family Member Transportation Enrollment Form
• W-9
• Transportation Billing Form - Blank
• Transportation Billing Form - Instructions and Completed Example 

Service Coordinators

All required forms for Service Coordinators who enroll in Missouri First Steps are listed below:

• Service Coordinator Enrollment Checklist
• Service Coordinator Information & Online Access Form
• Complete a Fingerprint/Background Check 
  • Applicant’s Privacy Rights
  • Scheduling a Fingerprinting Appointment The four digit registration number for First Steps applicants is 2298. 
  • FAQ for Fingerprinting/Background Check Procedures 
• Family Care Safety Registry
• Lobbying, Debarment, Suspension Form

IMPORTANT: For new System Point of Entry (SPOE) contractors, documentation of the SPOE Agency must be on file prior to Service Coordinator enrollment. Complete the documentation required for SPOE agencies on the SPOE Agency Enrollment Checklist.