Provider Application, Part A Form, 2021 - State of Michigan-2026

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The document is the Provider Application: Part A for the Michigan State Loan Repayment Program, which collects personal, educational, professional, and practice site information from applicants. It outlines eligibility requirements, including U.S. citizenship and employer contribution agreements, and gathers details about current loans and service obligations. The application aims to facilitate loan repayment for healthcare providers working in designated areas.

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Click ‘Get Form’ to open the Provider Application, Part A Form in our editor.
Begin by filling out your Personal Information. Enter your last name, first name, middle name, and select your gender. Provide your home address, phone numbers, email addresses, and confirm U.S. citizenship status.
Proceed to Educational and Professional Information. Indicate your professional designation and specialty. Fill in your license number, state of licensure, NPI number, and details about your education including college attended and graduation dates.
In the MSLRP Agreement Information section, select the appropriate statement regarding employer contributions and indicate if you are applying for priority status.
Complete the Participant Status Information by answering whether this is your first MSLRP loan repayment agreement and providing details of any current or past agreements.
Fill out the Practice Site Information section with details about your employment at practice sites including expected hours worked per week.
Finally, provide Loan Information by listing current loans and any original loans that have been consolidated. Ensure all information is accurate before signing the certification statement.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (54 Votes)
2020	4.3 Satisfied (190 Votes)
2018	4.1 Satisfied (37 Votes)

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What is the Medicaid eligibility form for Michigan?

MI DHS-4574 is a form used by the Michigan Department of Health and Human Services (MDHHS) to collect information regarding an individuals eligibility and circumstances related to public assistance programs.

What is the phone number for Michigan home help provider?

You can find contact information for your local office at .michigan.gov/dhs-countyoffices. Call the information number and press 0 after the message. Tell the person who answers the phone that you dont know your workers name. They will take your name and connect you to the right person.

How do I speak to someone at DHS Michigan?

If you have questions regarding provider enrollment in CHAMPS, contact Provider Support Services at 800-979-4662 or visit the MDHHS Home Help provider website at Michigan.gov/HomeHelp. To find your local MDHHS office, visit: Michigan.gov/ContactMDHHS.

michigan dhs forms

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What is the phone number for the Michigan MDHHS provider?

For assistance in enrolling please call 1-800-292-2550 option 4. MDHHS utilizes provider email address information entered in the CHAMPS provider enrollment application to communicate with providers.

How do I find out who is my caseworker at DHS Michigan?

Elizabeth Hertel is the director of the Michigan Department of Health and Human Services.