PROVIDER CONTRACT APPLICATION

PROVIDER CONTRACT APPLICATION
It may take up to 90 days for the application to be reviewed by our contracting review committee. We are sorry for the delay but be assured your application will remain on file with us and will be reviewed as soon as possible.

NOTE: Network Providers must be enrolled with the State of Minnesota Department of Human Services as MHCP Providers.

Network Providers must comply with the provider disclosure, screening, and enrollment requirements in 42 CFR §455. [Minnesota Statues, §256B.69, subd. 37; and 42 CFR §438.602(b)]
LEAVE NOTHING BLANK Please print or type all information. If the question does not apply, enter N/A.
Name of Organization with DBA *
Parent Organization(if different from Organization name)
Federal Tax ID# *
NPI or UMPI *
Website
Business Email as it will be listed in the Provider Directory
example@example.com
Provide the following information for contact people.

Title

	Name	Telephone	Email Address
Person Responsible for Contracting
CEO / Director / Owner
Credentialing
Organizational Assessments

Provider Specialty (select all that apply)
Mental Health

Adult Rehabilitative Mental Health Services (ARMHS) Assertive Community Treatment (ACT) Certified Community Behavioral Health Clinic (CCBHC) Children's Group Residential Treatment Facility (CGRTF) Children's Therapeutic Services and Supports (CTSS) Consolidated Chemical Dependency Treatment Fund (CCOTF) In-patient Mental Health Facility Intensive Residential Treatment Services (IRTS) Outpatient Mental Health Psychiatry Substance Use Disorder Treatment (SUD) SUD Comprehensive Assessment Targeted Case Management Other
Specialty Services

Acupuncture Audiology Chiropractic Essential Community Providers Occupational Therapy Optometry Oral Surgery Physical Therapy Physician Specialists Speech Therapy Specialty Hospital Other Other
Hospital/Clinic/Surgery/Free Standing Facility/Skilled Nursing

Ambulatory Surgery Center Critical Access Hospital Dialysis Federally Qualified Health Center Free Standing Clinic Free Standing Facility Free Standing Birth Center Hospice Hospital Hospital Based Clinic Primary Care Clinic Provider Based Clinic Rural Health Clinic Skilled Nursing Facility
Transportation / Home Care / Lab / DME / Interpreter

Non-Emergency Medical Transportation Emergency Medical Transportation Home Health Home Health w/Skilled Nursing Home and Community Based Services Community Health Worker Personal Care Agency Doula Services Public Health Social Services Independent Laboratory Durable Medical Equipment Home Infusion Interpreter
Type of Services offered by your Organization and why are they unique:
Do you offer Telehealth Services

Yes No
Type of Telehealth Services?

Phone Video Other
Describe the ways you provide services to specific segments of the population i.e. cultural, LGBTQ, gender, race/ethnicity?
Do you provide interpreter services for your clients/customers?

Yes No
If yes which languages:
List hospitals you have admitting privileges at, or other facilities you are affiliated with for services
Are you enrolled as a Medicaid provider with the State of Minnesota?

Yes No
TJC (The Joint Commission) Accredited?

Yes No
Are you Medicare (CMS) Certified:

Yes No
If yes Medicare Facility ID
Primary Location #1
County
City
State
Zip
Phone Number
Fax Number
Mailing Address:
County
City
State
Zip
Additional practice locations - If needed, copy this page and complete for each location associated with the primary facility.
Next Location's Legal name
IMPORTANT: This should be the business name you use to file income to the IRS. (This is also the first line of the W-9 Form
Doing Business As name
Federal tax ID #
NPI or UMPI#
Physical address
City, State, Zip
County
Telephone
Toll Free / TDD
Fax
Type of Services provided at this location
Next Location's Legal name:
IMPORTANT: This should be the business name you use to file income to the IRS. This is also the first line of the W-9 Form
Doing Business As name
Federal tax ID #: .
NPI or UMPI#: .
Physical address
City, State Zip
County
Telephone:
Toll Free / TDD
Fax
Type of Services provided at this location
I certify that the information provided on this form is true and correct.
Application signor name (print) *
Title
Application signor signature *

Clear
Date *

Month Day Year
Date
Telephone number *
Email address *
example@example.com
South Country Health Alliance serves a diverse population in our member counties and has had multiple instances of members requesting primary care or therapy providers who speak the primary language of the member and/or resembles the appearance of the member. Currently a significant amount of time is put into finding a provider for the member.

In an effort to gather diversity information about our provider network we ask that you complete the question below.

Please indicate the percentage of your Primary Care, Specialty Care or Mental Health Providers who identify as one of following groups:

	Primary Care %	Mental Health %	Specialty Care %
1. Asian
2. Black or African American
3. Hawaiian or Pacific Islander
4. Hispanic or Latinx
5. Middle Eastern
6. Native American or Alaskan Native
7. White
8. Multiracial or Biracial
9. A race/ethnicity not listed here
Please specify for #9

Return this form to providerinfo@mnscha.org
Should be Empty: