Rmation a. Last Name b. First Name e. Home Address: c. Middle Name f. City: i. Home Phone: j. Cell Phone: l. Personal Email: m. Work Email: o. Date of Birth (mm/dd/yyyy): d. Male Female g. State: h. Zip Code: k. Direct Work Phone: n. Additional Email: p. SIGMA Customer/Vendor ID Number: 2. Educational and Professional Information Professional Designation: MD DO Nurse Practitioner/Specialist (Masters) Physician Assistant Other (Specify): b. Specialty.
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How to fill out the MI Provider Application Form and Declaration of Intent online
Filling out the MI Provider Application Form and Declaration of Intent is a crucial step for individuals seeking to participate in the Michigan Opioid Treatment Access Loan Repayment Program. This guide provides clear instructions on how to accurately complete the form online to ensure a smooth application process.
Follow the steps to successfully complete the application form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering your personal information in section 1. This includes your last name, first name, middle name, home address, and all relevant contact details such as home phone, cell phone, and email addresses. Ensure that all information is accurate and up-to-date.
- In section 2, provide your educational and professional information. Indicate your professional designation, specialty, license number, state of licensure, and NPI number. It is important to specify your qualifications correctly.
- For section 3, fill in details regarding your opioid treatment practice. This includes your opioid treatment certification, certificate number, current OTP capacity, caseload, and the type of opioid treatment provided. Make sure to answer whether treatment is offered.
- In section 4, answer questions related to your eligibility and practice site information. List your practice facility name, its address, and confirm whether it is your primary site. If you practice at other locations, provide their details accordingly.
- Section 5 concerns loan information. List any current loans, their account or ID numbers, loan programs, and lenders. Be sure to indicate if any loans entail a service obligation requirement by circling those loans.
- Lastly, complete section 6, which is the certification statement and declaration of intent. Carefully read and affirm your understanding of the requirements and obligations tied to the program, including any necessary signatures and dates.
- After completing all sections, review the form for any errors. Once satisfied, save your changes, and proceed to download, print, or share the completed form as needed.
Take the first step towards enhancing your practice by completing the MI Provider Application Form and Declaration of Intent online today.
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