MO HealthNet Internet

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• MO HealthNet Internet
• Provider Training Program
• Presented by the Provider Education Unit
• MO HealthNet Division

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Proper Completion of the Medical Referral Form of
Restricted ParticipantsAlso Known as PI-118 Form

• Presented by the Provider Education Unit
• MO HealthNet Division

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• If a provider feels that a participant is
• improperly using benefits, the provider is
• requested to notify the MO HealthNet
• Division, Program Integrity Unit, P.O. Box
• 6500, Jefferson City, MO 65102 or you may
• contact the Program Integrity Unit at 573-
• 751-3399.

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Name of Participant
MO HealthNet ID Number
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Authorized (Lock-in) Provider Name
MO HealthNet Provider Identifier
Provider Taxonomy Code
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Signature of Authorized (Lock-in) Provider
Date (Month/Day/Year)
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Date of Service (Month/Day/Year)
Reason For Referral
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Referring To Provider
Provider Address
Provider Phone Number
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Provider Vendor (NPI) Number
Provider Taxonomy Code
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Obtaining a Copy of the Paper Form

• To Obtain a paper copy of the form, go to
• the MHD public Web site,
• www.dss.mo.gov/providers/index.htm. In
• the left hand column, click on MO HealthNet
• Forms. Then scroll down the list and click on
• Medical Referral Form of Restricted
• Participants (PI-118). You can print the form
• once it opens up on your computer screen.

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• Thank you again for participating in this
• training program. If you have questions
• regarding the information in this
• presentation, please contact the Provider
• Education Unit at 573-751-6683.