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Click ‘Get Form’ to open the nm mi via vendor packet in the editor.
Begin by entering the 'Participant Name' and 'Medicaid Card Number' in the designated fields. Ensure accuracy as this information is crucial for processing.
In the 'Waiver Service Procedure Code/Modifier' field, input the correct code as per your approved budget. This step is essential for compliance.
Describe the item being purchased clearly in the provided section, ensuring it aligns with your approved budget items.
Fill in the 'Request Date' and ensure it falls within your current approved Mi Via budget timeframe.
Enter the full payment amount, including all applicable taxes, in the specified field.
Complete the vendor information by filling out 'Payee Name', 'Vendor Federal Tax ID#', and address details accurately.
Attach a valid vendor cost quote or invoice before submitting your request through fax or mail as instructed.

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vendor packet example

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