Get Mn Hennepin Health Organizational Assessment Application 2020-2025

Filling out the MN Hennepin Health Organizational Assessment Application is an essential step for organizations seeking credentialing and participation with Hennepin Health. This guide provides a clear and detailed overview of each section of the application to assist users in completing it accurately and efficiently.

Follow the steps to successfully complete your application

1. Press the ‘Get Form’ button to access the MN Hennepin Health Organizational Assessment Application and begin filling it out.
2. Input the credentialing contact's information, including their name, email, and phone number. Ensure accuracy as this is key for communication.
3. Fill in the date of completion at the top of the form to indicate when the application is being submitted.
4. Complete the corporate identification information; provide the legal business name as shown on the W-9, the 'doing business as' name if applicable, your federal EIN/tax ID, and organizational NPI.
5. Indicate the length of time your tax ID has been in business.
6. Select the classification of your organization. Choose the appropriate option, such as Corporation, Partnership, or Not-For-Profit Corp, and if necessary, specify other classifications.
7. Identify the facility type by checking the applicable box like Skilled Nursing Facility or Hospital. If you are unsure, refer to the classifications provided.
8. Specify if the entity is wholly or partially owned by a hospital or healthcare system and provide the name if applicable.
9. Indicate if your entity is Medicare certified and supply your Medicare PTAN number and date of last certification if applicable.
10. List the provider types and specialties your organization serves.
11. If there are additional locations, respond with 'Yes' or 'No' and follow instructions for providing a roster.
12. Complete the facility information section, including the facility name, address, county, and contact numbers.
13. Attach copies of all necessary licenses including DHS and Board & Lodging/Supervised Living, along with insurance coverage documents.
14. Answer questions related to service accessibility and ensure to provide accurate information regarding ADA compliance and other accessibility features.
15. Fill out the credentialing information required about the medical director or equivalent, including their specialty and other credentials.
16. Submit disclosure responses and any necessary explanations regarding the organization's legal history.
17. Review all provided information for accuracy and completeness before signing the application.
18. Finalize your application by saving changes, downloading a copy, or printing to share, ensuring you retain a copy for your records.

Complete your MN Hennepin Health Organizational Assessment Application online today to ensure compliance and participation.