Mississippican enrollment 2025

1. Click ‘Get Form’ to open the MississippiCAN Enrollment form in the editor.
2. Begin with Section 1: Personal Information. Fill in the required fields, including your Beneficiary Name, Date of Birth (in mm/dd/yyyy format), and either your Medicaid ID # or Social Security #. Ensure that your Mailing Address, City/State, County, and Home or Cell Phone are accurately entered.
3. Proceed to Section 2: Primary Care Physician Information. Indicate whether you have a primary care physician by selecting YES or NO. If you select YES, provide the physician's name (first and last), along with their City, County, Facility Name, and Telephone Number.
4. In Section 3: Your Signature, sign the form and enter the date to confirm your submission.
5. Once all sections are completed, review your entries for accuracy before submitting the form.

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