1. Print and complete the MC-19 (Instructions are on the MC-19-I) and applicable medical assistance provider addendums per the list below by provider type. Provider enrollment instructions continue below the list of addendums.
Forms are available at https://public-dhhs.ne.gov/Forms/Default.aspx
Provider Agreement Forms
Service Provider Agreement-used by all provider types: MC-19
Service Provider Agreement Instructions: MC-19-I
Additional Forms
Electronic Funds Transfer (EFT) (Required for new providers): MS-84
Ownership/Controlling Interest and Conviction Disclosure (Required for enrollment and to report changes. Form is fillable. Complete on line, then print and mail to DHHS): MLTC-62
Authorization for Direct Deposit or US Bank ReliaCard (HCBS/NFOCUS providers only): FA-100
W-9 Tax Identification Number and Certification form: W-9
Service Provider Agreement Addendum Forms
Service Provider Addendum - HCB/NFOCUS only: MC-190
Provider Release of Info/Felony-Misdemeanor Statement - HCB/NFOCUS only: MC-199
Non-Emergency Transportation Addendum: MC-211
2.
Attach additional information. - MS-84 – Required for all providers
- MLTC-62 – Required for all providers
- W-9 Tax Identification Number and Certification form - Required for all providers
- Copy of license – Required for all licensed provider types
- Medicare/CNN CMS Certification Number, if applicable.