Get Mi Dhhs Practice Site Application And Declaration Of Intent 2020

Completing the MI DHHS Practice Site Application And Declaration Of Intent is essential for organizations seeking to participate in the Michigan State Loan Repayment Program. This guide will provide you with a clear, step-by-step process to ensure your application is filled out accurately and efficiently.

Follow the steps to successfully complete the application online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the Sponsoring Agency Information section. Provide the name, Federal ID number, and physical address of the sponsoring agency, including city, state, zip, and county. Make sure to include the administrator's name, title, email, and direct phone number.
3. Proceed to the Provider and Agreement Information section. Here, enter the applicant's last name, first name, middle name, title, and discipline. Include the employment start date and indicate whether the agreement is for provider recruitment or retention.
4. In the next part, select the appropriate descriptor for your employer contributions based on the agency's nonprofit status and indicate whether you are requesting priority status for selection.
5. Move to the Practice Site Information section. Confirm that the applicant will be employed for at least 40 hours per week and that practice sites are not-for-profit by answering the corresponding yes or no questions.
6. List the practice site details by entering the name, physical address, and the number of hours the provider will work each week. Provide the practice site manager's contact information and select all relevant indicators that describe the practice site's classification.
7. Repeat step 6 for additional practice sites if applicable, providing similar information for each site listed.
8. In the Certification of Compliance and Declaration of Intent section, review and verify that the information provided aligns with the program requirements before signing and dating the document.
9. Finally, save your changes, ensuring your application is downloaded and stored securely for future reference. You can also print or share the completed form as needed.

Complete your MI DHHS Practice Site Application And Declaration Of Intent online today to secure your participation in the Michigan State Loan Repayment Program.