Mississippi medicaid 2026

1. Click ‘Get Form’ to open the Mississippi Medicaid Hospice Election Package in the editor.
2. Begin with the Election Statement Form 1165-A. Fill in the Beneficiary Name exactly as it appears on their Medicaid card, followed by the Beneficiary Medicaid Number.
3. Complete the address fields, including Street Address, City, State, and Zip Code. Ensure that all information is accurate.
4. If applicable, have the Beneficiary/Legal Guardian/Representative sign and date the form. The Provider Signature must also be present.
5. Proceed to the Enrollment Form 1165-B. Repeat similar steps for filling in personal details such as Social Security number and Medicare number.
6. List diagnosis codes and ensure that all required signatures are obtained before finalizing your document.

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