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MHCP Enrolled Provider

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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