Rule 19-3-11.12 - Instructions for Completing the Mississippi Participating Physician ApplicationTo effectively use the Application, the following is suggested:
Type or legibly complete the Application in black ink.
A. Complete all of the Application except for line 1, "This application is submitted to,___". Do not sign and date the original. Keep the completed original on file and keep a blank original for future up-dates. Sign and date as directed below.B. When submitting the Mississippi Participating Physician Application to a credentialing entity: 1. copy the original Application and any addenda the credentialing entity has requested;2. fill in the name of the IPA, medical group, health plan, hospital, etc., to which the Application is being submitted on the top of page 1;3. sign and date the copy in the spaces provided;4. mail the signed and dated copy to the requesting organization.C. By doing the above, your signature will be an original and the date will be current. Remember that the information on the Application must be complete and accurate. An incomplete Application may delay processing.D. Submit completed Applications and do not rely on attached information unless requested.E. If an item in the Application does not apply to you, write N/A in the box provided.F. Attach copies of the documents requested on page 1 of the Application each time the Application is submitted.G. For your convenience and to ensure information accuracy, keep Application current at all times. If you have any questions, please call the Managed Care Entity to which you are submitting this Application.
19 Miss. Code. R. 3-11.12
Miss Code Ann §§ 83-5-1; 83-41-413 (Rev. 2011)