| Publication Date | File | File Size | File Type |
|---|
| 01/01/2022 | Carrier ID
| 563k | PDF |
| 10/27/2021 | W-9
| | |
| 04/01/2020 | NH Medicaid Provider Participation Agreement (PPA)
| 538k | 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 |
| 01/22/2013 | FORM 357 - PROOF OF COMPLIANCE FORM EMPLOYEE EDUCATION ABOUT FALSE CLAIMS RECOVERY
| 37k | 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 |
