Mhcp Form Dhs 4087 Eng PDF Details

Are you trying to get the Minnesota Health Care Program (MHCP) form DHS 4087-ENG? This highly important document is a critical part of enrolling in MHCP. The information provided in it MUST be accurate, or your application may not be accepted. In this blog post, we will explain what this form is and how you can successfully navigate its completion so that you have an approved MHCP coverage plan as soon as possible.

QuestionAnswer
Form NameMhcp Form Dhs 4087 Eng
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMedicare MN Provider set up form for EDI mhcp provider setup form

Form Preview Example

DHS-4087-ENG 9-08

Minnesota Health Care Programs (MHCP)

Provider Setup Form

For use by Billing Intermediaries and Clearinghouses only.

Use this form to notify DHS whenever providers are ADDED OR REMOVED from your list. Copy as needed.

SUBMITTER ID (UMPI)

SUBMITTER NAME

 

 

A677480100

Office Ally

 

 

 

 

 

 

NAME OF PERSON COMPLETING THIS FORM

ADDRESS

 

 

Dan Waclawsky

16703 SE McGillivray, Suite 200

 

 

 

 

 

 

PHONE

CITY

STATE

ZIP CODE

( 866 ) 575-4120

Vancouver

WA

98683

 

 

 

 

MHCP Pay-To Provider

PAY-TO PROVIDER NAME

NPI/UMPI

 

LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

 

 

 

PAY-TO PROVIDER CONTACT NAME

PHONE NUMBER

REMOVE LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

(

)

 

 

 

 

 

 

 

 

 

PAY-TO PROVIDER SIGNATURE

 

DATE (MM/DD/YYYY)

CHOOSE ONE:

 

 

 

 

 

฀฀฀l฀CLAIM

l฀ERA

l฀BOTH

 

 

 

 

 

 

MHCP Pay-To Provider

 

 

 

 

 

 

 

 

 

PAY-TO PROVIDER NAME

NPI/UMPI

 

LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

 

 

PAY-TO PROVIDER CONTACT NAME

PHONE NUMBER

REMOVE LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

(

)

 

 

 

 

 

 

 

 

 

PAY-TO PROVIDER SIGNATURE

 

DATE (MM/DD/YYYY)

CHOOSE ONE:

 

 

 

 

 

฀฀฀l฀CLAIM

l฀ERA

l฀BOTH

 

 

 

 

 

 

MHCP Pay-To Provider

 

 

 

 

 

 

 

 

 

PAY-TO PROVIDER NAME

NPI/UMPI

 

LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

 

 

PAY-TO PROVIDER CONTACT NAME

PHONE NUMBER

REMOVE LINK TO OUR SUBMITTER ID – EFFECTIVE DATE (MM/DD/YYYY)

 

(

)

 

 

 

 

 

 

 

 

 

PAY-TO PROVIDER SIGNATURE

 

DATE (MM/DD/YYYY)

CHOOSE ONE:

 

 

 

 

 

฀฀฀l฀CLAIM

l฀ERA

l฀BOTH

 

 

 

 

 

 

FAX THIS FORM TO MHCP PROVIDER ENROLLMENT AT (651) 431-7462 OR MAIL TO

DHS PROVIDER ENROLLMENT

PO BOX 64987

ST. PAUL, MN 55164-0987

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