When finished hit Submit or return this form to firstname.lastname@example.org
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)]
I certify that the information provided on this form is true and correct.