Site UPDATE - Minnesota Department of Health - health state mn 2025

1. Click ‘Get Form’ to open the Site UPDATE application in the editor.
2. Begin by filling in the 'Practice Site' section. Enter the name, street address, city, state, zip code, county, and phone number of your practice site.
3. Next, complete the 'Clinic Contact' section with the contact person's name, title, phone number, and email address.
4. In the 'Loan Repayment Applicant Provider' section, provide the name and degree of the provider along with their projected start date. Indicate if they are currently at the site and whether they will meet full-time or part-time requirements.
5. Fill out the 'Site Encounter Data' by entering total patient encounters and percentages for sliding-fee patients, Medicaid patients, Medicare patients, and those below 200% poverty.
6. If applicable, describe any site challenges that have improved due to previous participation in the program.
7. Ensure that an authorized site official initials all assurances listed in the form before signing and dating it.
8. Finally, submit your completed application along with any supporting documents by mail or fax before the deadline.

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