Provider Contract Application

Provider Contract Application
Fill out all information. If the question does not apply, enter N/A. Blank fields could result in a denied application.
Name of Organization with DBA
Parent Organization (if applicable)
Federal Tax ID#
NPI or UMPI
Website
Business Email
example@example.com
Mailing Address
City
State
Zip
County
Primary Location #1 Address
City
State
Zip
County
Phone Number
Please enter a valid fax number
Fax Number
Please enter a valid fax number.

Service Section
Do you offer Telehealth Services?

Yes No
Type of Telehealth Services:

Phone Video
Do you provide interpreter services for your clients/customers?

Yes No
If Yes, which languages?
Are you enrolled as a Medicaid provider with the State of Minnesota?

Yes No
The Joint Commission Accredited?

Yes No
Are you Medicare (CMS) Certified?

Yes No
Medicare Facility ID
List hospitals you have admitting privileges at, or other facilities your are affiliated with for services, if applicable.
Provide the following information for contact people.

Person Responsible for:

	Name	Telephone	Email Address
Contracting
CEO/Director/Owner
Credentialing
Organizational Assessment

Describe the type of services offered by your organization and why they are unique
Describe the ways you provide services to specific segments of the population (i.e. cultural, gender, race/ethnicity, LGBTQ+)
BEHAVIORAL HEALTH PROVIDERS (Please check all that apply)

Adult Day Treatment Outpatient Psychotherapy Adult Rehabilitative Mental Health Services (ARMHS) Outpatient Substance Use Disorder Treatment Assertive Community Treatment (ACT) Partial Hospitalization Program Behavioral Health Home Peer Recovery Support Certified Community Behavioral Health Clinic (CCBHC) Psychiatry Children’s Day Treatment Psychological/Neuropsychological Testing Children’s Group Residential Treatment Facility (CGRTF) Recovery Community Organization Children’s Therapeutic Services and Support (CTSS) Residential Substance Use Disorder In Patient Mental Health Facility Substance Use Disorder Treatment (SUD) Intensive Residential Treatment Services (IRTS) SUD Comprehensive Assessment Outpatient Mental Health Targeted Case Management (TCM) Other
SPECIALTY PROVIDERS (Please check all that apply)

Acupuncture Early Intensive Developmental and Behavioral Intervention (EIDBI) Oral Surgery Specialists Audiology Essential Community Providers Physical Therapy Speech Therapy Chiropractic Occupational Therapy Optometry Physician Specialty Hospital Other
HOSPITAL/CLINIC/SURGERY CENTER/FREE STANDING FACILITY/SKILLED NURSING FACILITY (Please check all that apply)

Ambulatory Surgery Center Free Standing Clinic Hospice Primary Care Clinic Critical Access Hospital Free Standing Facility Hospital Provider Based Clinic Dialysis Free Standing Birthing Center Rural Health Clinic Federally Qualified Health Center Hospital Based Clinic Skilled Nursing Facility Other
HOME CARE/DME/LAB/ INTERPRETER (Please check all that apply)

Doula Services Home Infusion Public Health Durable Medical Equipment Independent Laboratory Social Services Home Health Interpreter Other: Home Health w/ Skilled Nursing Personal Care Agency (PCA) Other
TRANSPORTATION PROVIDERS (please check all that apply)

Non-Emergency Medical Transportation (NEMT) Emergency Medical Transportation

Please check all that apply below for non-emergency and include how many vehicles of each you service. Additionally list the counties you service.

	Type	How Many?	Counties Serviced
Ambulatory
Lift/Ramp
Stretcher
Unassisted
Wheelchair
Volunteer Drivers

Second Location Information (if applicable)
Legal Name with dba
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.
Federal Tax ID
NPI
Phone Number
Physical Address
City, State Zip
County
Fax Number
Toll Free/TDD
Do you provide Telehealth Services?

Yes No
Types of telehealth services?

Phone Video
Types of Services provided at this location

Third Location Information (if applicable)
Legal Name with dba
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.
Federal Tax ID
NPI
Phone Number
Physical Address
City, State Zip
County
Fax Number
Toll Free/TDD
Types of Services provided at this location
Do you provide Telehealth Services?

Yes No
Types of telehealth services?

Phone Video

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

	Behavioral Health	Drivers	Primary Care	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 which race/ethnicity for #9
When finished hit Submit or return this form to providerinfo@mnscha.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.
Application signor name (Print)
Title
Application signor signature

Clear
Date

Month Day Year
Date
Signor Email Address
example@example.com
Signor Phone Number
Should be Empty:

Provider Contract Application

Provide the following information for contact people.