Form Mad 217 - Pe/mosaa Determiner Update - Human Services Department
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1PE/MOSAA DETERMINER UPDATE
Please print information in appropriate box
I.
LIST CHANGES IN THIS SECTION
Determiner Name
Determiner Number
Previous Provider
Current Provider Name
–
STREET ADDRESS
Number/Street or Road/P.O. Box Number (Current Provider)
City
State
Zip Code
MAILING ADDRESS – (If different from the Street Address) (Current Provider)
City
State
Zip Code
Business Telephone Number/Extension
FAX Number
E-Mail Address
II
REQUEST FOR REMOVAL FROM DETERMINER FILE
.
ATTN: Supervisors, Managers of Determiners.
Please fill out this Section if a PE determiner is no longer with your organization.
Please remove the individual named below from the PE Determiner file. Removal of the individual will result in a de-activation of the Determiner number.
Determiner Name
Determiner Number
Provider
Business Telephone Number/Extension
FAX Number
E-Mail Address
III. VERIFICATION OF INFORMATION
Determiner Name
Determiner Number
Provider
STREET ADDRESS – Number/Street or Road/P.O. Box Number
City
State
Zip Code
MAILING ADDRESS – (If different from the Street Address)
City
State
Zip Code
Business Telephone Number/Extension
FAX Number
E-Mail Address
Name of Person Submitting Update
Signature
Date
Email form to:
Presumptive Eligibility Program
HSD Medical Assistance Division
Communication and Education Bureau
HSD.PEDeterminers@state.nm.us
Or Fax to 505-827-6275
Information Has Been Sent to Fiscal Agent
MAD
USE
____________________________________________
_________________
Signature:
Date:
Information Has Been Updated or
Information Has Not Been Updated (See Comments Below):
FISCAL
AGENT
____________________________________________
_________________
Signature:
Date:
COMMENTS: ______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
MAD 217 Revised 10/22/14
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Parent category: Medical