Get Dch 1625 Form In Michigan
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How to fill out the DCH 1625 Form in Michigan online
Filling out the DCH 1625 Form is an important step for providers seeking enrollment in Michigan's Medicaid and State Medical Programs. This guide offers clear instructions on how to complete the form online, ensuring you accurately provide all necessary information.
Follow the steps to successfully complete the DCH 1625 Form online.
- Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
- Begin by filling out the applicant information section, which includes your name, professional title, state license number, and social security number. Ensure all names are exactly as licensed.
- In the employer information section, provide your employer's name and federal employer identification number. This is required documentation.
- Indicate your specialties in the appropriate section. For this, you must attach proof, such as board certification or state licenses.
- Complete the service and practice address, billing address, and correspondence information as needed. If you want notifications sent to a different address, make sure to include that.
- For ownership information, list the individual owners if applying as a corporation or business. Include their names, percentage of ownership, and dates of ownership.
- Fill out the criminal convictions section as required. If you have a conviction related to Medicare or Medicaid, include this information.
- Ensure that the agreement is signed by both you as the applicant and your employer/owner or agent. Each signature indicates agreement to the terms outlined.
- Once all sections are completed, review the form for accuracy. Save your changes, download a copy for your records, and prepare to submit the original form by mail.
Complete your DCH 1625 Form online to get started with your provider enrollment.
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Fill Dch 1625 Form In Michigan
I certify that the above signatory has the authority to execute this agreement. Replaces Form No. DCH-1625. Michigan Medicaid Provider Enrollment is no longer accepting any new paper applications (DCH1625). Medicaid Assistance Provider Enrollment Agreement (DCH-1625). 3. Request for Taxpayer Identification Number and Certification Form W-9 (or other proof). Forms for Providers. Included on this page are Change and Enrollment forms as well as Michigan Department of Health and Human Services forms. Enrollment Agreement (form DCH-1625) for EACH practice location. • You must ALSO submit copies of the following documents with this form and the DCH-1625 for. Ensure DCH1625A and Foster Care Agreement are completed and maintained on file.
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