Passport Agreement Amendment to Increase Caseload Capacity 01/2019
Providers should complete this amendment to the Passport provider agreement when increasing member caseload capacity.
Passport Provider Change Form 01/2019
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 01/2019
Passport providers may use this form when providing a referral for their members to another provider.
Passport to Health Provider Agreement 01/2019
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.
Primary Care Case Management Agreement 03/2019
Providers should complete this amendment to the Passport provider agreement when adding new providers to a group practice.
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.
Member Disenrollment Letter 12/2019