Get Mi Provider Application: Part A 2021-2025

The MI Provider Application: Part A is an essential document for participants seeking benefits under the Michigan State Loan Repayment Program. This guide provides clear instructions to assist users in filling out the application online effectively and accurately.

Follow the steps to complete your MI Provider Application: Part A online.

1. Press the ‘Get Form’ button to access the MI Provider Application: Part A. This will allow you to open the form in your preferred editing platform.
2. Begin by entering your personal information. Fill in your last name, first name, middle name, home address, and contact information. Ensure accuracy in details such as home phone, work phone, personal email, and date of birth. You will also need to indicate your U.S. citizenship status and race/ethnicity.
3. Next, provide your educational and professional information. Select your professional designation, specify your specialty, and enter your license number, state of licensure, NPI number, most recent college or university attended, graduation date, and residency program information if applicable.
4. In the MSLRP agreement information section, select the appropriate statement that describes your employer's contribution agreement related to the loan repayment. Indicate if you are requesting priority status and your National Health Service Corps status.
5. For participant status information, answer whether this application is for your first MSLRP loan repayment agreement. If not, fill in the details of your current and previous agreements under the provided sub-sections for start and end dates, agreement amounts, and payments received.
6. Complete the practice site information section by confirming your employment status and providing details about your primary practice site and additional sites, including hours worked and expected dates of employment.
7. Lastly, fill out loan information by listing current loans and original loans that have been consolidated. Certify the information by signing and dating the application.
8. Once all fields are completed, save your changes, and ensure you download or print a copy for your records. You may also share the completed form as needed.

Complete your MI Provider Application: Part A online today!