Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

2018

04/04/2018  Updated Passport Eligible Populations & Reimbursement

Passport Agreement Amendment to Add Providers 08/2013

Providers should complete this amendment to the Passport provider agreement when adding new providers to a group practice.

Passport Agreement Amendment to Increase Caseload Capacity 08/2013

Providers should complete this amendment to the Passport provider agreement when increasing member caseload capacity.

Passport Provider Change Form 07/2014

Medicaid/HMK Plus members can use this form to change Passport providers/ Provider changes will not take effect until the month following the request.

Passport Referral Form 07/2013

Passport providers may use this form when providing a referral for their members to another provider.

Passport to Health Provider Agreement 02/2014

Providers who wish to become a Passport provider should be an active Medicaid provider and have primary care within his/her professional scope of practice.

This agreement is a portion of the Montana Healthcare Programs enrollment package, and the page numbering reflects that document.

W-9 Form 12/2011

This is the approved form to use for Montana Healthcare Programs/ Providers must submit a W-9 form when changing their pay-to/1099.

Requirements for a Member Disenrollment Letter 08/2013