Get Merc Training Site Application - Minnesota Department Of Health - Health State Mn

The MERC Training Site Application is a crucial document for facilities seeking grant funding from the Minnesota Department of Health. This guide will provide you with clear, step-by-step instructions to effectively complete the application online.

Follow the steps to complete the MERC Training Site Application accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your facility name, address, city, state, and ZIP code. Make sure all information is current and aligns with your records.
3. Identify the CEO/CFO or authorized representative by entering their name, title, email address, phone number, and fax number.
4. Select your Medicaid provider type from the options provided such as facility, hospital, physician clinic, pharmacy, dental clinic, chiropractic clinic, or other. If applicable, specify the ‘other’ type.
5. Input your Federal Tax ID (FEIN) and National Provider ID (NPI). Be sure to input these accurately as they are essential for your application.
6. If your facility’s NPI is shared or consolidated, include the taxonomy and ZIP+4 to ensure proper identification for your training facility.
7. If your hospital has separately enrolled provider-based clinics/departments, list these under the 'Hospital subparts' section. Input the subpart name, address, NPI, and FEIN.
8. Indicate if the potential grant should be mailed to the training site address you provided above. If no, input the alternative mailing address for the CEO/CFO or authorized representative.
9. Provide your name and title in print, along with your signature to certify the accuracy of the information. Also, include the date of completion.
10. Review the completed application for accuracy, then save your changes, download, print, or share the form as needed.

Complete your MERC Training Site Application online today to secure your funding.