HAP Enrollment Form for CHW Doula MIHP MiDPP
This file is an enrollment form for Community Health Workers, Doulas, and providers of the Maternal Infant Health Program and Michigan Diabetes Prevention Program. It outlines the necessary information and instructions for enrollment. Ensure to follow all steps carefully to successfully complete your application.
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How do I fill this out?
To fill out this form, begin by providing your personal information in the fields provided. Ensure that all information is accurate and complete before submission. Don't forget to sign and date the form at the end.
How to fill out the HAP Enrollment Form for CHW Doula MIHP MiDPP?
1
Complete all required fields in the form.
2
Review the information you provided for accuracy.
3
Sign and date the form where indicated.
4
Prepare the additional documents needed for submission.
5
Email the completed form and documents as instructed.
Who needs the HAP Enrollment Form for CHW Doula MIHP MiDPP?
1
Community Health Workers need this form to enroll in authorized programs.
2
Doulas require this form to get recognized for services provided.
3
Providers of the Maternal Infant Health Program must complete this for proper documentation.
4
Individuals applying for the Michigan Diabetes Prevention Program should fill this form out.
5
Healthcare professionals seeking to provide services need this enrollment to ensure compliance.
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What are the instructions for submitting this form?
To submit this form, you must complete all fields accurately and attach the necessary documents. Email the form and accompanying documentation to providernetwork@hap.org, ensuring to include 'CHW/Doula/MIHP/MiDPP' in the subject line. For any inquiries, you may contact the provided email, and for fax submissions, include the form along with supporting documents.
What are the important dates for this form in 2024 and 2025?
Make sure to submit the enrollment form as soon as possible. For 2024, submissions are due by March 2024 for timely processing. Keep an eye on any updates for 2025 to ensure compliance.
What is the purpose of this form?
The purpose of this form is to facilitate the enrollment of Community Health Workers, Doulas, and other providers in essential health programs. It ensures that all necessary information and documentation is collected to maintain program integrity. Furthermore, this form allows for the proper management and coordination of services offered to individuals in need.
Tell me about this form and its components and fields line-by-line.
- 1. Name: Full name of the applicant including first, middle, and last name.
- 2. Gender: Indicate your gender: Male or Female.
- 3. Race/Ethnicity: Optional field for demographic information.
- 4. NPI Number: National Provider Identifier for individual applicants.
- 5. Office Address: Complete address of the applicant’s office.
- 6. Billing Information: Details about where payments should be sent.
- 7. Provider Signature: The applicant’s signature for verification.
- 8. Date: The date when the form is completed.
What happens if I fail to submit this form?
Failure to submit this form can result in denial of participation in essential programs. This may also lead to delays in obtaining services and supports you need. It is crucial to ensure that all information is submitted correctly to avoid any issues.
- Denial of Participation: Without proper submission, your application may be rejected.
- Service Delays: Not submitting can lead to delays in receiving necessary health services.
- Missing Critical Information: Inaccurate submissions can result in the omission of important details.
How do I know when to use this form?
- 1. Community Health Worker Enrollment: To enroll as a Community Health Worker.
- 2. Doula Services Registration: For new Doulas to get recognized for their services.
- 3. Maternal Infant Health: Necessary for those applying within this health program.
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