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MO HealthNet Internet Provider Training Program

Presented by the Provider Education UnitMO HealthNet Division

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Proper Completion of the Medical Referral Form of Restricted

ParticipantsAlso Known as PI-118 Form

Presented by the Provider Education Unit

MO HealthNet Division

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If a provider feels that a participant is

improperly using benefits, the provider is

requested to notify the MO HealthNet

Division, Program Integrity Unit, P.O. Box

6500, Jefferson City, MO 65102 or you may

contact the Program Integrity Unit at 573-

751-3399.

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MO HealthNet ID Number

Name of Participant

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Authorized (Lock-in) Provider Name

MO HealthNet Provider Identifier

Provider Taxonomy Code

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Signature of Authorized (Lock-in) Provider

Date (Month/Day/Year)

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Date of Service (Month/Day/Year)

Reason For Referral

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Referring To Provider

Provider Address Provider Phone Number

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Provider Vendor (NPI) Number

Provider Taxonomy Code

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Obtaining a Copy of the Paper Form

To Obtain a paper copy of the form, go to

the MHD public Web site,

www.dss.mo.gov/mhd/providers/index.htm. In

the left hand column, click on “MO HealthNet

Forms”. Then scroll down the list and click on

“Medical Referral Form of Restricted

Participants (PI-118)”. You can print the form

once it opens up on your computer screen.

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Thank you again for participating in this

training program. If you have questions

regarding the information in this

presentation, please contact the Provider

Education Unit at 573-751-6683.