Get Md Program Participation Agreement 2017-2026

Completing the MD Program Participation Agreement online is a straightforward process designed to help hospitals apply for participation in the Hospital Presumptive Eligibility program. This guide aims to provide clear instructions on each section of the form to ensure a smooth application process.

Follow the steps to fill out the MD Program Participation Agreement.

1. Click the ‘Get Form’ button to access the MD Program Participation Agreement and open it in your preferred document editor.
2. Fill out Part I, which includes the hospital's contact information. Provide the name of the hospital, any other names used, and the primary contact's name and title. Additionally, ensure to include the hospital's mailing address, contact telephone number, fax number, and email.
3. In Part I, you will need to enter the hospital's Medical Assistance Provider Number and National Provider Identification Number. Don't forget to estimate the number of uninsured patients seen each month.
4. Proceed to Part II, which must be completed by an authorized hospital representative. Ensure this individual holds one of the designated titles such as Chief Executive Officer or Director of Patient Accountability.
5. In Part II, certify the hospital’s participation as a Medicaid provider and detail the responsibilities to be upheld by the hospital staff regarding Hospital Presumptive Eligibility determinations.
6. A representative must date and sign the form at the bottom of Part II. Clearly print their name and title for identification.
7. Review the completed agreement for accuracy and completeness before the final submission.
8. Once everything is filled out, you can save the changes, download the document, print it, or share it as needed. Lastly, return the completed form to the provided email address.

Complete your MD Program Participation Agreement online today!