(601) 359-6294 Attn: B2I - Mississippi Division of Medicaid-2026

1. Start by clicking ‘Get Form’ to open the referral form in our editor.
2. Fill in the 'Referral Date' and 'Referral By' fields at the top of the form. Ensure that your contact information is accurate for effective communication.
3. Provide details about the resident, including their name, phone number, date of birth, Medicaid number, Medicare number, and Social Security number.
4. If applicable, enter the contact name of a guardian or legal representative along with their relationship to the resident.
5. Indicate whether the resident has a guardian or legal representative and if they are aware of this referral. Fill in any necessary details regarding their legal relationship.
6. Complete sections regarding the resident's facility admission date and preferred county of transition. Answer questions about housing assistance needs and previous attempts to transition back to the community.
7. Check desired services from the list provided and specify any additional comments or how you heard about B2I.
8. Review all entered information for accuracy before submitting. Once completed, save your document and send it via fax to (601) 359-6294 Attn: B2I.

Experience seamless document editing today—start using our platform for free!