It is preferred that all forms are completed electronically. However, if you are unable to complete electronic forms, the following forms can be printed, completed and submitted to PremierFMS.

• Direct Deposit Agreement
• Release of Confidential Information
• Participant Reimbursement Request
• 2025 Payment Schedule
• 2024 Payment Schedule

Start Up

• Provider Application
• Provider Agreement
• IRS W-9
• Direct Deposit Agreement
• NPP and Individual Provider Attestation of Eligibility to Work

Supplemental Forms

• Background Information Disclosure (BID)
• Background Information Disclosure (BID) Addendum
• Contact Change

Payment Information

• Claim Form
• Mileage Log
• 2025 Payment Schedule
• 2024 Payment Schedule

Start Up

• Non-Professional Provider Set-Up
• IRS W-9
• Direct Deposit Agreement
• NPP and Individual Provider Attestation of Eligibility to Work

Supplemental Forms

• Background Information Disclosure (BID)
• Background Information Disclosure (BID) Addendum
• Contact Change

Payment Information

• Claim Form
• Mileage Log
• 2024 Payment Schedule