Adult Brain Injury Program Providers
As a licensed/certified provider, you are essential to the health and well being of Missourians with special health care needs.
- Adult Brain Injury Provider Information Brochure
- ABI Program Provider Manual
- ABI Program Prior Authorization
- ABI Treatment Plan
- ABI Program Prior Authorization Modification & Monthly Progress Report Form
- Frequently Asked Questions for Treatment Forms (2014)
- Electronic Signature Information for PDF Forms (2014)
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 form should be utilized:
New Provider Enrollment and Re-Enrollment Information
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:
- Participation Agreement for Professional and Special Services Provider (DH-74A)
- Provider Application (CC-35)
- Vendor Input/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)
- Provider Application (CC-35)
- Vendor Input/ACH-EFT Application
Contractor Information
Resources
- Missouri Brain Injury Advisory Council
- Missouri Protection and Advocacy
- Brain Injury Association of Missouri
- Brain Injury Association of Kansas and Greater Kansas City
- National Institute of Neurological Disorders and Stroke