New Jersey > Statewide > Medicaid Management Information System
Signature Authorization Form - New Jersey
| Signature Authorization Form Form. This is a New Jersey form and can be used in Medicaid Management Information System Statewide . |
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For Molina Medicaid Solutions Internal Use Only Provider Name: Doc Type: Provider ID #: Provider Type: Provider Specialty: CHNGREQ SIGNATURE AUTHORIZATION FORM Date: Dear Provider: If anyone other than the practitioner is authorized to sign and certify Medicaid claims and supporting documents, the signature of that person must appear on the claim form as indicated below (NOT THE PRACTITIONER'S NAME). If the authorized individual is the Medicaid Provider, he/she must sign the Authorization Form. In addition to the above, an authorized representative(s) who is an employee of your office should only complete this form. Should your office utilize a billing firm or agency, a letter signed by yourself must be submitted indicating the name(s) of those individuals you have authorized to sign. The name(s) should be printed and then the actual signature affixed by that individual. The letter should contain the name of the billing firm or agency which has been approved to provide your billing. If your application is for the group ple ase provide the GROUP NAME in the Provider Name field. If the application is for an individual please provide the Individual Provider name in the Provider name field. Note: Only Originals. No Faxes or Copies are accepted. Provider Name: Provider ID #: Address: NPI#: City: State: Zip: Please Print or Type Full Name Actual Signature(s) RETURN TO: Molina Medicaid Solutions Attn: Provider Enrollment Unit P.O. Box 4804 Trenton, NJ 08650-4804 PPE-39 (07/10) American LegalNet, Inc. www.FormsWorkFlow.com
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