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.

ABI Program Provider Manual NEW 2015 (view and/or print)
ABI Program Prior Authorization Modification Form (2013)
ABI Program Prior Authorization (2013)

ABI Monthly Progress Report Addendum          (2014)
ABI Treatment Plan Goal Addendum-Revision  (2014)
Treatment Plan-Monthly Progress-3 Goal     (2014)
Treatment Plan-Monthly Progress-5 Goal     (2014)

INSTRUCTIONS for Progress Report, Treatment Plan - Monthly Progress(2014)
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 forms should be utilized:
Health Insurance Claim Form, CMS-1500
UB-04 (hospitals)

New Provider Enrollment
Please 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:
Missouri Department of Health and Senior Services Terms and Conditions
State of Missouri Contract Business Associate Provisions
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
Service Coordinator List

Resources
Missouri Brain Injury Advisory Council
Missouri Protection and Advocacy
Brain Injury Association of Missouri
Brain Injury Association of Kansas and Greater Kansas City
Traumatic Brain Injury and Public Services in Michigan
National Institute of Neurological Disorders and Stroke