Public Health Clinic Enrollment Criteria and Forms

Revised: January 5, 2023

To enroll as a public health clinic with Minnesota Health Care Programs (MHCP), the clinic must be operated under the direction of a unit of government; city or county.

Enrollment Criteria

Providers who wish to enroll with MHCP or make enrollment requests can do so in one of the following two ways.

· Register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal. Also, upload the Provider Agreement (DHS-4138) (PDF) in the MPSE portal.

or

· Complete the following documents required to enroll as a public health clinic provider and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Organization – Provider Enrollment Application (DHS-4016A) (PDF)

· Provider Agreement (DHS-4138) (PDF)

· Disclosure of Ownership and Control Interest (DHS-5259) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional)

Review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF).

We process forms in date order received. Allow 30 days for processing. If we need more information to complete your enrollment, we will send a request for more information letter via your MN–ITS mailbox or U.S. Postal Service explaining what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services (CMS) final federal provider screening regulations.

Refer to Revalidation in the Provider Screening Requirements section of the MHCP Provider Manual for more information about how to complete your revalidation.

Reporting Changes

Report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Rules 9505.0380 (Public Health Clinic Services)
Code of Federal Regulations, title 42, section 440.90 (Clinic services)