Common Contracts
1 similar Electronic Signature Agreement contracts
ContractElectronic Signature Agreement • December 13th, 2018
PROVIDER ELECTRONIC SIGNATURE AGREEMENT COVER SHEET Michigan Department of Health and Human Services Instructions • Provider should retain a COPY in the office • MUST be submitted with DCH-1401, Electronic Signature Agreement. Mail to: Email to: Michigan Department of Health and Human Services ProviderEnrollment@michigan.gov Provider Enrollment Section PO Box 30238 Lansing, MI 48909 Fax: 517-241-8233 Reason for Submission (check all that apply) Revalidation New Tax ID/SSN (List Provider Enrollment staff contact name) Domain Access Other (List reason) Group Individual Both Domain Administrator Contact Information Contact Information (REQUIRED) Name Email Address Phone Number MILogin User ID Provider’s NPI Number Provider’s Date of Birth Provider’s Home Address Provider Enrollment Office Use Only Provided Domain Administrator contact information Sent/Gave to team lead for processing Sent to processor with W-9 attached Opened for
