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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How to fill out the MI DHHS Practice Site Application And Declaration Of Intent online
The MI DHHS Practice Site Application And Declaration Of Intent is a crucial document for those participating in the Michigan State Loan Repayment Program. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently.
Follow the steps to complete the application with ease.
- Use the ‘Get Form’ button to access the MI DHHS Practice Site Application And Declaration Of Intent. This will allow you to open the document in an editor for completion.
- Begin with Section 1: Sponsoring Agency Information. Fill in the name of the sponsoring agency, federal ID number, complete address, city, state, zip, and county. Include the administrator's name, title, email address, and direct phone number.
- Continue to Section 2: Provider & Agreement Information. Enter the provider's last name, first name, middle name, and title. Select the provider's discipline or specialty and provide the employment start date along with the provider's email address.
- In Section 2, indicate whether the MSLRP agreement will be for provider recruitment or retention. Choose the appropriate statement regarding employer contributions to the loan repayment agreement.
- Move to Section 3: Practice Site Information. Answer whether the applicant will be employed at the practice site for 40 hours per week for at least 45 weeks per year. Indicate if all practice sites are not-for-profit.
- For each practice site listed, provide the site's name, physical address, city, county, state, and zip code. Specify the hours per week the provider will be employed and the estimated opening date if under construction.
- Check all applicable descriptions for each practice site and provide percentages of the total caseload that utilize a sliding fee scale or are billed to Medicaid.
- Complete Section 4: Certification of Compliance and Declaration of Intent. Review and certify compliance with all requirements, ensuring that all information provided is accurate.
- Finally, add the signature of the administrator, indicating agreement with the certification statement. Save the completed form, and choose to download, print, or share it as needed.
Complete your MI DHHS Practice Site Application And Declaration Of Intent online today to take advantage of this opportunity.
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