Practice Information Questionnaire

Note: only complete what applies

X/Twitter
This field is for validation purposes and should be left unchanged.
Primary Practice Location:
Legal name of practice:
Physical address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Fax:

Payment/mailing address (if different than physical address):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary contact:
Phone
Fax:
Email
Billing contact:
Phone
Fax:
Email

Group NPI:
Federal Tax ID:
Fiscal Year End (default is 12/31):
Requested Effective Enrollment date:
Month
Day
Year
Does office comply with ADA accommodations
Is the office, including parking, entry ways, other relevant spaces accessible for people with disabilities?
- Yes
- No
Are your office exam rooms accessible for people with disabilities?
- Yes
- No
Does your office have equipment accessible for people with disabilities?
- Yes
- No
Select one of the following encounter indicator options that describes your enrollment record:
- Fee-for-service and managed care organization (MCO) in-network: Fee-for-service (FFS) providers see members on Medical Assistance (MA) who are not enrolled with a managed care organization (MCO). In a FFS delivery system, providers bill MA directly and receive reimbursement for each covered service. MCO in-network providers are providers who see MHCP members who are enrolled with an MCO and bill for those services through the MCO.
- MCO in-network only: MCO in-network only is for providers who are enrolled with one or more MCO and provide services to members who are enrolled with that MCO. Services provided to members through an MCO are billed through that MCO.
Note: Choosing the MCO in-network only option means you will not provide services to FFS members.

Ownership and Disclosure
Entity Legal name (according to IRS):
First Middle Last
DBA (if applicable):
State Tax ID #:
Please check as applicable and copy and complete if more than 1:
Full legal Name:
First Middle Last
Social Security Number:
Date of birth:
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does any person, business or organization you listed have an ownership or control interest in any other Medicaid disclosing entity or any entity that does not participate in Medicaid, but is required to disclose ownership and control interest because of participation in any Title V, XVIII, or XX programs?
- Yes – complete the following for each person, business or organization
- No
Has any person having an ownership or control interest ever:
Been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the start of these programs?
- Yes
- No
Had civil money penalties or assessments imposed under section 1128A of the Social Security Act?
- Yes
- No
Been excluded from participation in Medicare or any of the state health care programs?
- Yes
- No
List any other owners

Has any managing employee or agent ever:
Been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the start of these programs?
- Yes
- No
Had civil money penalties or assessments imposed under section 1128A of the Social Security Act?
- Yes
- No
Been excluded from participation in Medicare or any of the state health care programs?
- Yes
- No
PCA providers only
Complete the following information for all residential properties you own, lease or manage that could be or are used for providing home care services.
Full legal name of residence or provider (Taxpayer name of FEIN or on W-9 from IRS)
First Middle Last
Do you own, lease or manage the property?
- Own
- Lease
- Manage
Address of property:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hours of operation
Including evening/weekend hours, and holidays, if applicable
Do you offer 24-hour emergency service?
- Yes
- No
Where are medical records stored?
- Off Site
- Electronic System
Name of electronic system
Please provide Address if offsite
Street Address Address Line 2 City State ZIP Code
What are your specialties (please list)?
Click the plus symbol to add more
For behavioral health: please list modalities used
Click the plus symbol to add more
Document Upload
W9, IRS EIN letter, state license(s) and/or certificate(s), certificate of insurance
Drop files here or

Max. file size: 100 MB, Max. files: 10.

Does office comply with ADA accommodations