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Missouri Medicaid Audit and Compliance Unit (MMAC) fax number
(573) 634-3105
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Missouri Medicaid Audit and Compliance Unit (MMAC), Provider Enrollment Unit
Used for: 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.
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.
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