DHS-2351-X, Bridges Provider Enrollment/Change Request
|BRIDGES PROVIDER ENROLLMENT / CHANGE REQUEST |
|Michigan Department of Health and Human Services |
| |
| New Enrollment |License Number (AFC/HA, CDC, CFC) | Change Enrollment |Bridges Provider ID Number |
| | | | |
|Enrolling County Name |Requester Name |Request Date |
| | | |
|PROVIDER INFORMATION |
|Prefix |First |Middle |Last |Suffix |
| | | | | |
|SSN |DOB |Individual # |
| - - |MM/DD/YYYY | |
|SIGMA Vendor Code |Organization Name |FEIN |
| | | |
|LARA License # (Home Repair Only) |Gender |Phone # |
| | Male Female | - - |
|PROVIDER ADDRESS INFORMATION |
|Address Type |SIGMA Address ID | |SIGMA Address ID |
| Physical Address | | Mailing Address | |
|Supplemental Address Line |Supplemental Address Line |
| | |
|Street Number |Fraction |Pre-Direction |Street Number |Fraction |Pre-Direction |
| | | | | | |
|Street Name / Rural Address |Street Name / Rural Address |
| | |
|Street Type |Post-Direction |Dwelling Type |Number |Street Type |Post-Direction |Dwelling Type |Number |
| | | | | | | | |
|Address Line 2/P O Box |County |Address Line 2/P O Box |County |
| | | | |
|City |State |Country |City |State |Country |
| | | | | | |
|Zip Code |International Zip Code |Is address validation required:|Zip Code |International Zip Code |Is address validation required:|
| - | | Yes No | - | | Yes No |
|PROVIDER SERVICE INFORMATION |
|Service Type |Tax Indicator |
| | |
|Service Begin Date |Service End Date |
|MM/DD/YYYY |MM/DD/YYYY |
|Closure Reason |Closure Action Date |
| |MM/DD/YYYY |
|Payment To: Physical Mail Address |Correspondence To: Physical Mail Address |
|EFT Indicator |IV-E Indicator |W-9 Indicator |
| | | |
|Fuel Type |Account Number Indicator |License # |
| | | |
|New Provider ID Number | |
| | |
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