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... Enrollment Application (DHS-4015) Individual Provider Enrollment Application (DHS-4016) Organization – Provider Enrollment Application (DHS-4016A) Personal Care ...
Description: This page lists all Provider Eligibility and Compliance (PEC) enrollment forms that accept electronic signatures
Date:
July
31, 2026
... with DHS, refer to
Individual Provider
Enrollment Application (DHS-4016) (PDF)
and
Enrollment with Minnesota Health Care Programs ( ...
Description: IEP and IFSP CPT Code FAQs
Date:
December
18, 2025
... Profile section of the
Individual Provider Enrollment Application (DHS-4016) (PDF)
, complete
and submit the
Fee-for Service ( ...
Description: November 4, 2025 MHCP Provider News
Date:
November
18, 2025
... Profile section of the
Individual Provider Enrollment Application (DHS-4016) (PDF)
, complete
and submit the
Fee-for Service ( ...
Description: October 21, 2025 MHCP Provider News
Date:
November
04, 2025
... 431-7462:
• MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF) • Minnesota Health Care Programs (MHCP) Provider Agreement ( ... the following:
• MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF) • MHCP Provider Agreement (DHS-4138) (PDF) • EIDBI ...
... Enrollment at (651) 431-7462:
• MHCP Provider Application (DHS-4016) (PDF) • MHCP Provider Agreement (DHS-4138) (PDF) • MHCP ...
... Provider Agreement (DHS-4138) (PDF) • MHCP Enrollment Application (DHS-4016) (PDF) • MHCP Applicant Assurance Statement (DHS-5308) (PDF) ...
... 431-7462:
• MHCP Individual Practitioner - Provider Enrollment Application (DHS-4016) (PDF) • Select provider type Allied Dental Professional 31 • ...
... 431-7462:
• MHCP Individual Practitioner - Provider Enrollment Application (DHS-4016) (PDF) • Select provider type Allied Dental Professional 31 • ...
... 4022C (PDF)
MHCP Individual Practitioner Provider Enrollment Application DHS-4016 (PDF)
MHCP Organization - Provider Enrollment Application DHS-4016A ( ...