Provider Relations 1-on-1 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. Please select your provider specialty below. **Please note: Home Help Providers should call 1-800-979-4662 or email ProviderSupport@michigan.gov for assistance. Ambulance Clinics Dental Durable Medical Equipment (DME) Home Health Hospice Hospital - Inpatient or Outpatient Practitioner/Physician Private Duty Nursing (PDN) Skilled Nursing Facility (SNF) Vision Other (please specify) Question Title * 3. Please tell us your Billing NPI. Question Title * 4. Are you currently enrolled as a Michigan Medicaid provider? Yes No Question Title * 5. Briefly describe what information you would like the Provider Consultant to discuss in your training. Done