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Get MI DHHS Practice Site Application And Declaration Of Intent 2020

N 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 (App.

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