Provider Relations Association Request

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* 1. Contact Information

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

Email Address *

Phone Number *

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* 2. Are you currently enrolled in Michigan Medicaid?

Yes

No

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* 3. Please provide your National Provider Identifier (NPI) if applicable

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* 4. What is the name of your association?

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* 5. What type of association do you represent?

Dental - ADA Billing

Institutional - UB04 Billing

Professional - HCFA 1500 Billing

Both

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* 6. What is the date, or approximate date you would like a Michigan Medicaid representative to attend your meeting or conference?