MEDICAID FORMS

[page updated October 2021]
Service providers: for your convenience, all pertinent forms for users of the SSoM Medicaid Service Portal are listed below with options to view/download. ALL forms with student information should be faxed to the SSoM office at (406) 624-6289 or sent using our secure webfile service:
ShareFile. Please DO NOT send student names via email.
CLICK TO VIEW  AND/OR DOWNLOAD THESE FORMS
Student Information Sheet​ ​
If a student is missing in the Service Portal this sheet should be filled out and sent to SSoM. This is a fillable PDF file : )
Child Profile Form with Instructions ​
​This form should be filled out for students requiring a Paraprofessional for Personal Care.
Service Portal Instructions
Gives logging guidelines for new and existing users (updated 2018)
Consent to Bill Medicaid 
​​This form should be filled out for a student on an IEP.  Be sure the parent checks the box to allow or deny the district from submitting eligible claims. Logs can be submitted to Montana Medicaid only after the date of the parent signature. ​
Annual Billing Notice
Required by Montana Medicaid to be sent or given to parents annually once the Consent to Bill Medicaid form ​has been signed.
Instructions for Nursing and Personal Care
Personal Care Services Daily Sheet
PROGRAM CONTACT

Lisa Waterman
Medicaid Billing Program Specialist
E-mail: lwaterman* (see below)
(406) 272-0073