Get Mi Provider Application: Part A 2020

The MI Provider Application: Part A is an essential document for individuals seeking participation in the Michigan State Loan Repayment Program. This guide offers clear instructions on how to complete the application online efficiently and accurately.

Follow the steps to fill out the application with ease.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling in your personal information. Enter your last name, first name, and middle name in the designated fields. Select your gender and provide your home address, including your city, state, and zip code.
3. Provide your contact information. Fill in your home phone and cell phone numbers, as well as your personal email address. Make sure to also include your work phone and work email.
4. Indicate your citizenship status by selecting 'Yes' or 'No' and provide your date of birth. You will also need to enter your Social Security Number and indicate the races with which you identify.
5. In the educational and professional information section, select your professional designation from the provided options. Fill in your specialty, license number, state of licensure, and NPI number. List the college or university you attended along with the dates relevant to your education and residency.
6. For the MSLRP agreement information, choose the statement that accurately describes your agreement with your employer. Indicate your provider type if you wish to request priority status.
7. Provide details related to your participant status, including whether this is your first MSLRP loan repayment agreement and information about any current or past agreements.
8. Complete the practice site information section by confirming your employment status and detailing your practice site, including name, address, county, and expected hours worked per week.
9. In the loan information section, list your current loans, including their account numbers and names. If you have original loans that have been consolidated, provide that information as well.
10. Finally, read the certification statement and ensure to sign and date the application before submitting it.
11. Once completed, you may save changes, download, print, or share the form as needed.

Get started on your application by filling out the MI Provider Application: Part A online today.