Residential Care Facility or Assisted Living Facility Enrollment Packet

1. RCF/ALF Provider Profile Form
2. Business Organizational Structure Form (BOS) and  all documents as indicated by the section of the form completed. Complete only one section, based on how your business is registered with the IRS and DOR, and provide all the required supporting documents for that section.   BOS Resource/Guide
3. Notification from the Internal Revenue Service of the applying provider’s Federal Employer Identification Number.
4. Notification from the Missouri Department of Revenue of the business entity’s Missouri Employer Identification Number.
5. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
   Information available at   http://dor.mo.gov/forms/943.pdf
6. Notification from CMS/NPPES of the applying provider’s assigned Type 2 organizational National Provider Identification (NPI) number. Go to  https://nppes.cms.hhs.gov/ to obtain and print out confirmation of your assigned NPI.
7. A copy of the RCF/ALF license issued by the Section for Long Term Care Regulation.
8. RCF/ALF Questionnaire Form
9. MMAC HCBS Enrollment Application Form
10. Title XIX Participation Agreement
11. Electronic Funds Transfer Form. Attach a pre-printed voided check OR a letter from your bank with the legal name of the account holder, routing number and account number.
12. On a separate sheet of paper or attachment (i.e. organizational chart, spreadsheet, etc.) identify individuals and businesses with direct participant contact, ownership or control interests, and all “managing employees” as defined in 13 CSR 65-2.010(25). Those attachments must contain the full name (First, middle, last and suffix Jr., Sr., etc. – including maiden names and any aliases), date of birth, and social security number of each individual who has 5% or greater direct/indirect ownership, controlling interest, partnership interest; any contractor or subcontractor; managing employees; officers or directors; or the legal business name and federal EIN of any organization(s) having direct or indirect ownership or controlling interest.
13. Provide documentation from DHSS showing the owners and managing employees listed in number 12 with direct Medicaid participant contact are registered with the Family Care Safety Registry (FCSR). Go to  https://webapp02.dhss.mo.gov/bsees/ to register.
14. Lease agreement or deed for the facility location.
15. Copy of confirmation of Application Fee Payment –  App Fee Vendor Site

Please fax the completed application and supporting documents listed above to 573-634-3105 for review

All applications are processed and reviewed in the order they are received. Upon receipt of this enrollment packet, your application will be reviewed. MMAC staff will contact you if additional information is required.

If you have questions or need assistance completing the enrollment packet, please contact the MMAC Contracts Unit at  mmac.ihscontracts@dss.mo.gov

MMAC does not accept photos of documentation taken with a cell phone or camera for enrollment purposes.