Get Dhs 4474

Completing the Dhs 4474 application for enrollment with Minnesota Health Care Programs is a straightforward process that can be accomplished online. This guide will provide you with detailed instructions to help ensure that your form is filled out correctly and submitted successfully.

Follow the steps to fill out the Dhs 4474 form with ease.

1. Click the ‘Get Form’ button to obtain the Dhs 4474 document and open it in your preferred online editor.
2. Begin by entering your Health Care Case Coordinator information. This includes selecting the provider type, entering your name (first, middle, last), and providing your social security number. Make sure to include your email address and your preferred enrollment date.
3. Next, fill in the organization information section. This requires entering the organization name, NPI, address, city, state, phone number, and ZIP code. Additionally, provide the county and fax number where applicable.
4. In the provider statement section, certify the information provided by checking the appropriate box. Include your contact name, phone number, and email address.
5. Finally, ensure that the name of the coordinator is printed clearly, sign the application, and date it. Review all fields for accuracy before moving to the next step.
6. Once you have completed the form, you can save changes, download, print, or share the document as needed. Ensure the completed form is then faxed to (651) 431-7462 for processing.

Begin filling out the Dhs 4474 online to ensure efficient enrollment with Minnesota Health Care Programs.