Mh 228 Form PDF Details

At the intersection of mental health services and administrative protocol lies the MH-228 form, a critical document for mental health professionals working within or in affiliation with the Department of Mental Health. This comprehensive form is not merely paperwork; it is a gateway for mental health providers to register, update, or terminate their professional details in an official capacity. It caters to various requests like initiating service as a new provider, updating existing information, or even going through the process of termination. Specifically, it requires detailed personal information, including names, contact details, and licensure specifics, ensuring that the mental health provider’s credentials are up to date and accurately reflected in the Department of Mental Health's records. The form also segments into identifying whether the provider is an individual, a group, or an organization, further clarifying the nature of services offered. Taxpayer IDs and other financial identifiers are crucial for those operating on a fee-for-service basis, emphasizing the form’s role in sorting out both legal and bureaucratic necessities. Aimed at facilitating better service delivery and operational efficiency, the MH-228 form stands as a testament to the organized, systematic approach adopted by the Department of Mental Health. Its careful design enables a seamless interface between mental health professionals and administrative benchmarks, ensuring that providers can focus more on delivering quality care, unencumbered by procedural complexities.

QuestionAnswer
Form NameMh 228 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesRPfill ableNPI dmh rendering provider form

Form Preview Example

RENDERING PROVIDER FORM

Mail to: Department of Mental Health Chief Information Office Bureau Systems Access Unit

695 South Vermont Avenue Los Angeles, CA 90005

Request Type

Submit Date

 

 

License

 

 

 

 

 

New

 

Update Reporting Unit

 

Terminate

 

 

Name Change

 

 

Effective Date

 

 

 

 

 

General Information

Last Name:

First Name:

Middle Initial:

Sex:

F

Ethnicity

 

 

 

 

DMH/NGA Staff Code

FFS Ind Prov No.

SSN (Last 4 only)

Language Code

Select DMH Classcode:

DMH

Prov name:

DHS

Prov name:

Non-Governmental Agency (DMH Contracted) L.E. #:

L.E. Name:

FFS Individual

 

FFS Group

 

FFS Org

Tax Payer ID

(FFS only)

Contact & Assigned Location Information

Contact name:

Contact phone no: (

)

Contact Email:

Contact Fax No: (

)

Add this rendering provider in the service location indicated below: (please use form MH-228A for additional locations)

Delete this rendering provider in the service location indicated below.

 

Delete this rendering provider in ALL service locations within the legal entity indicated above.

DMH/NGA Prov No./Rept Unit

FFS Group/Org Prov No.

(Please enter the provider no. associated to the above taxpayer ID)

Effective

Date

Name of Organization:

Address:

Termination

Date

Locum Tenum

Service Area City:

Intern

MHSA

Zip:

Taxonomy and License Information (Required if request type is NEW)

Description:

Taxonomy

 

Professional

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description:

 

 

 

 

 

 

 

 

 

Taxonomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Professional

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective

 

 

 

 

 

 

 

 

 

 

 

Expiration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Prov No.

 

 

 

 

 

 

 

 

PPIN Medicare No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration

 

 

 

 

(DMH directly-operated only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(DMH directly-operated only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

NPI Effective Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Manager/Designee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

Print Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIOB USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rendering Provider IS No:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ticket #

 

 

Date Processed

Processed by:

Revised: 3/14/2007

MH-228

How to Edit Mh 228 Form Online for Free

Using PDF documents online is quite easy with this PDF tool. You can fill in Mh 228 Form here without trouble. The tool is consistently upgraded by our team, receiving new awesome features and growing to be better. To get the process started, take these simple steps:

Step 1: Click the "Get Form" button at the top of this page to get into our tool.

Step 2: As you access the file editor, you will see the form prepared to be completed. Other than filling in various fields, you may also perform some other actions with the form, that is putting on any textual content, modifying the original text, adding graphics, affixing your signature to the document, and more.

Filling out this form needs attentiveness. Make certain every single field is filled out properly.

1. Whenever filling in the Mh 228 Form, ensure to complete all needed blank fields in the relevant part. This will help speed up the process, making it possible for your information to be processed swiftly and properly.

Writing part 1 in Mh 228 Form

2. The subsequent stage would be to submit the following blanks: Contact phone no, Contact Fax No, Add this rendering provider in the, Delete this rendering provider in, Delete this rendering provider in, DMHNGA Prov NoRept Unit, FFS GroupOrg Prov No, Effective, Date, Termination, Date, Name of Organization, Address, Please enter the provider no, and Locum Tenum.

Contact phone no, Locum Tenum, and Please enter the provider no in Mh 228 Form

Many people generally make errors while filling in Contact phone no in this section. Be sure you re-examine whatever you enter here.

3. This stage is going to be straightforward - fill in every one of the empty fields in License, Medicare Prov No, DMH directlyoperated only, NPI, Authorized ManagerDesignee, PPIN Medicare No, DMH directlyoperated only, NPI Effective Date, Expiration, Date, Print Name, Date, CIOB USE ONLY, Rendering Provider IS No, and Ticket to complete this segment.

PPIN Medicare No, NPI Effective Date, and CIOB USE ONLY inside Mh 228 Form

Step 3: Ensure your details are accurate and just click "Done" to complete the process. Right after registering afree trial account with us, you will be able to download Mh 228 Form or send it via email right off. The PDF will also be readily accessible in your personal cabinet with your each change. FormsPal guarantees safe document completion without personal data record-keeping or distributing. Rest assured that your information is safe here!

Mh 228 Form isn’t the one you’re looking for?

Related Documents