Missouri Medicaid Audit and Compliance Unit (MMAC) fax number

Fax destination details

Department

Missouri Medicaid Audit and Compliance Unit (MMAC), Provider Enrollment Unit

Purpose

Submitting MO HealthNet provider enrollment documents and updates (e.g., Provider Enrollment signature pages, Provider Update Request, ADC-Provider Profile Form) to MMAC's Provider Enrollment Unit via the fax number 573-634-3105.

Form

ADC-Provider Profile Form (Provider Enrollment); Provider Update Request Form — ADC-Provider Profile Form (2022)

Address

205 Jefferson Street, 2nd Floor, Jefferson City, MO 65102

Voice phone

573-751-3399; 833-818-1183

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Complete Section I and II as required; print and sign the form; fax the completed form and any attachments to 573-634-3105 per MMAC enrollment instructions. Signature pages must be faxed to this number; additional supporting documents may be requested by MMAC.

Official form instructions are published as a downloadable file on the organization's website.