On a. Name of Sponsoring Agency: b. Federal ID #: c. Address d. City g. Administrator Name h. Title j. Administrator Email: l. e. State f. Zip i. County k. Administrator Direct Phone: Name & Email of assistant, HR staff or recruiter that will be copied on correspondence directed to the administrator: Name: Email: Type of Sponsoring Agency (e.g. health system, medical group, local public health, etc.): 2. Provider & Agreement Information Provider (Applicant) Last Name: Provider (Ap.
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How to fill out the MI DHHS Practice Site Application And Declaration Of Intent online
Completing the MI DHHS Practice Site Application And Declaration Of Intent online can streamline the process of participating in the Michigan State Loan Repayment Program. This guide will walk you through each section of the form, ensuring you provide accurate and complete information.
Follow the steps to successfully complete your application.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out the sponsoring agency information, including the name, federal ID number, address, city, state, zip code, county, and contact details of the administrator.
- Provide the provider's (applicant's) information. Include their last name, first name, middle name, title, discipline/specialty, email, and employment start date.
- Complete the provider agreement section by indicating the purpose of the MSLRP agreement—whether for provider recruitment or retention—and select the contribution agreement options.
- In the practice site information section, indicate if the applicant will work a minimum of 40 hours per week for at least 45 weeks per year and confirm if the sites are not-for-profit.
- Enter details for each practice site listed, including the name, address, and contact information for the practice site manager. Specify whether they meet the criteria like being a Certified Rural Health Clinic or a Community Health Center.
- Certify compliance with the practice site regulations by reviewing and ensuring that all outlined conditions are met. Complete the certification statement.
- Complete the declaration of intent, affirming the provider's employment throughout any loan agreements and compliance with program guidelines.
- Once all sections have been filled out, review your entries for accuracy and completeness. Save your changes, then download, print, or share the form as needed.
Complete your MI DHHS Practice Site Application And Declaration Of Intent online to ensure your participation in the Michigan State Loan Repayment Program.
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