Provider Relations Association Request Question Title * 1. Contact Information Name * Company * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address * Phone Number * Question Title * 2. Are you currently enrolled in Michigan Medicaid? Yes No Question Title * 3. Please provide your National Provider Identifier (NPI) if applicable Question Title * 4. What is the name of your association? Question Title * 5. What type of association do you represent? Dental - ADA Billing Institutional - UB04 Billing Professional - HCFA 1500 Billing Both Question Title * 6. What is the date, or approximate date you would like a Michigan Medicaid representative to attend your meeting or conference? Submit Request