MHCP Enrolled Provider

Minnesota Health Care Programs (MHCP) Provider Enrollment

Enrollment Applications and Agreements for All Other Provider Types

MHCP Provider Enrollment forms are in Portable Document Format (PDF).

Doc. #

Document Title

DHS-4016

MHCP Individual Practitioner Provider Enrollment Application

DHS-4016A

MHCP Organization Provider Enrollment Application

DHS-4138

MHCP Provider Agreement

DHS-4611B

MHCP Provider Agreement Volunteer Dentists

DHS-4646

Child and Teen Checkups Provider Agreement

DHS-3535

Individual Practitioner MHCP Provider Information Change Form

DHS-3535A

Group, Facility, or Billing Entity MHCP Provider Information Change Form

DHS-5211

Primary Care Physician and Vaccine Administration Applicant Assurance Statement

DHS-5259

Disclosure of Ownership and Control Interest

DHS-5308

MHCP Applicant Assurance Statement Community Health Workers

DHS-5550

MHCP Provider Entity Sale or Transfer Addendum

DHS-5732

MHCP Applicant Assurance Statement Community Health Clinic

DHS-5748

MHCP Applicant Assurance Statement Community Mental Health Center

DHS-5947

Home Infusion Pharmacy Applicant Assurance Statement

DHS-6095

Certified Mental Health Rehabilitation Professional Assurance Statement

DHS-6175

Independent Rural Pharmacy Add-on Applicant Assurance Statement

DHS-6287

MHCP Data Privacy Notice

DHS-6368

State Operated Services Provider Enrollment Application Supplement

N/A

Direct Deposit/Electronic Funds Transfer

 
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