Minnesota Uniform Credentialing ApplicationInitial (pdf): Fill out & sign online

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Click ‘Get Form’ to open the Minnesota Uniform Credentialing Application in the editor.
Begin with Section 1: Facility Identification. Fill in the legal business name, federal TIN, and business address if different from the facility address. Ensure all fields are completed without abbreviations.
Proceed to Section 2: Medical Director or Equivalent. Clearly identify the Medical Director's name, license number, and contact information.
In Section 3: Facility Type, select the appropriate facility type based on your licensure status. Make sure to check any additional services provided by hospitals if applicable.
Complete Sections 4 through 10 by providing necessary documentation such as licenses, Medicare status, and insurance coverage details. Attach required documents directly within our platform for convenience.
Finally, review all sections for accuracy before submitting your application via email or fax as instructed at the beginning of the form.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (103 Votes)
2018	3.8 Satisfied (33 Votes)

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