Children with Special Health Care Needs (CSHCN) Program Providers

SHCN

As a licensed/certified provider, you are essential to the health and well being of Missourians with special health care needs.

If you are interested in becoming a provider, contact the SHCN Central Office by phone or in writing to request an application packet or complete the forms below under “New Provider Enrollment” and mail originals to SHCN.

The following billing forms should be utilized:
Health Insurance Claim Form, CMS-1500
UB-04 (hospitals)

New Provider Enrollment
Please review the Missouri Department of Health and Senior Services Terms and Conditions as well as the State of Missouri Contract Business Associate Provisions and complete the following required enrollment forms for new provider enrollment:
Missouri Department of Health and Senior Services Terms and Conditions
State of Missouri Contract Business Associate Provisions
Participation Agreement for Professional and Special Services Provider (DH-74A) or Download OneForm
Provider Application (CC-35) or Download OneForm
Vendor ACH/EFT Application

Provider Address Change
The following forms shall be completed when the provider has a payment mailing address change:
Participation Agreement for Professional and Special Services Provider (DH-74A) or Download OneForm
Provider Application (CC-35) or Download OneForm
Vendor ACH/EFT Application

Tools
Provider Billing Guidelines
CSHCN Service Coordinator Map
Instructions to Open OneForm Documents