Form Sfn 509 PDF Details

Navigating the requirements for out-of-state facilities wishing to provide services to North Dakota Medicaid recipients involves understanding and completing the SFN 509 form. This form, issued by the North Dakota Department of Human Services Medical Services, is a crucial step for any facility looking to extend its services to Medicaid beneficiaries not within its immediate geographic location. It outlines a process where these facilities must demonstrate their capability and reason for billing North Dakota Medicaid by providing detailed information about at least one Medicaid-eligible recipient they plan to serve or have already served. The form asks for essential data including the patient or recipient's name, date of birth, address, a brief description and circumstances of services rendered, the referring physician, and the date of service. This ensures that the North Dakota Medicaid program can verify and process requests from out-of-state providers efficiently and effectively, aiming to expand access to care for its recipients while maintaining stringent oversight on the services paid for with Medicaid funds. Completion and submission of the SFN 509 to the Provider Enrollment sector of DHS Medical Services is the first step in a crucial journey toward broadening the scope of care and support available to North Dakota Medicaid recipients, making it an essential document for out-of-state providers.

QuestionAnswer
Form NameForm Sfn 509
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdept, recipient, SFN, sfn 509 nd

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OUT-OF-STATEENROLLMENT CLARIFICATION

ND DEPARTMENT OF HUMAN SERVICES

MEDICAL SERVICES

SFN 509 (12-2003)

Medical Services has received a request from your facility to become a North Dakota Medicaid Provider. Before your enrollment can be processed, you will need to answer the questions below. Out- of-state facilities must have at least one Medicaid eligible recipient they will be billing North Dakota Medicaid for services to be or already rendered.

Patient/Recipient Name

 

Date of Birth

 

 

 

Address

 

 

 

 

 

City

State

Zip Code

 

 

 

Brief Description and Circumstances of Services Rendered (This must be completed)

Referring Physician

Return to: Provider Enrollment DHS Medical Services

600 E. Boulevard Avenue-Dept. 325 Bismarck, ND 58505-0250

Date of Service

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Filling out part 1 of CLARIFICATION

2. Soon after filling out the last part, go to the next stage and enter the essential particulars in these fields - Referring Physician, Date of Service, Return tocidProvider Enrollment, and DHS Medical Services E Boulevard.

CLARIFICATION conclusion process shown (part 2)

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