Certified nurse-midwife

Qualification requirements

Certified nurse-midwives must: 

• Be a registered professional nurse who is legally authorized to practice as a nurse-midwife in the state in which the services are performed;

• Have successfully completed a program of study and clinical experience for nurse-midwives that is accredited by an accrediting body approved by the U.S. Department of Education; and

• Be certified as a nurse-midwife by the American College of Nurse-Midwives or the American Midwifery Certification Board

Documentation requirements and recommendations

• Completed CMS-855I form 
  
  Note: To expedite the processing of your provider enrollment application, you may use the internet-based PECOS, which will automatically select the appropriate form and allow you to complete the application process online.

• Signed and dated certification statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted. 
  
  Note: If you submitted your application through internet-based PECOS, you may sign the application electronically or you must submit your paper certification statement within 15 days of your electronic submission.

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) and associated documentation (e.g., copy of a voided check and / or a deposit slip). Please click here for more information. 
  
  Note: If a provider / supplier already receives payments electronically and is not making a change to his / her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.

• Include copies of the following supporting documents:

• A notarized copy or a certified “true copy” of the practitioner’s state medical license:

• A notarized copy must include the stamp that states “official seal” and the name of the notary public as well as the state, county, and date the notary’s commission expires.

• A certified “true copy” of an original document has a raised seal that identifies the state and county in which it originated or is stored.
  
  Note: A provider / supplier located in Puerto Rico or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers / suppliers will be considered valid if it was issued within 12 months of First Coast’s receipt of the enrollment application. The letters for U.S. Virgin Islands providers / suppliers will be considered valid if it was issued within six months of First Coast’s receipt of the enrollment application.
• Certificate of completion, transcript, and/or diploma from accredited educational program(s) required for certification and/or licensure (please refer to Qualification requirements section at the top of the page.