Get Dhs 4022

The DHS 4022 form, also known as the Provider Agreement Addendum for PCA Choice providers, is essential for participating providers in Minnesota Health Care Programs. This guide will help you easily navigate through the form's components and fill it out online with confidence and clarity.

Follow the steps to complete the DHS 4022 form online

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the name of the provider by printing or typing the business name in the designated field.
3. Fill in the name of the person signing the agreement. Ensure this is the individual authorized to enter into contracts on behalf of the provider.
4. If known, include the NPI or UMPI number in the specified field.
5. Provide the signature of the person signing the form to validate the agreement.
6. Indicate the title of the person signing the form to affirm their position within the organization.
7. Date the document in the appropriate field to mark when the agreement was completed.
8. Once all fields are filled out, retain a copy of the completed form for your records. You may also choose to save changes, download, print, or share the form as needed.

Complete and submit your DHS 4022 form online today.