Request New/Update Existing Essential Health Provider
This form will allow Medical Providers who wish to be listed on our Essential Community Providers (ECPs) list to provide all the necessary information to be added. It will also allow current ECPs to update their information. For your reference, the most recent ECP list can be found here: https://www.marylandhbe.com/wp-content/uploads/2015/06/2019-MHBE-Essential-Community-Health-Providers-FINAL.xlsx
Email address *
MHBE Number (Enter "New ECP Request" if this is a new application): *
Your answer
Site name where medical services are provided: *
Your answer
Organization Name *
Your answer
National Provider Identifier (if available, otherwise blank):
Your answer
Select your ECP Type: *
Required
Number of Medical Full-Time Practitioners on site (or number of Beds if a hospital): *
Medical and Dental FTEs may be listed as decimal numbers to indicate part-time status
Your answer
Number of Dental Full-Time Practitioners on site: *
Medical and Dental FTEs may be listed as decimal numbers to indicate part-time status
Your answer
Site Street Address: *
Your answer
Site City: *
Your answer
Site Zip Code: *
Your answer
Site County: *
Your answer
Organization Street Address: *
Your answer
Organization City: *
Your answer
Organization Zip Code: *
Your answer
Organization County: *
Your answer
Primary Contact Name: *
Your answer
Primary Contact Title: *
Your answer
Primary Contact Phone Number: *
Your answer
Primary Contact Phone Extension (if applicable):
Your answer
Primary Contact Email Address: *
Your answer
URL:
Your answer
Secondary Contact Name:
Your answer
Secondary Contact Title:
Your answer
Secondary Contact Phone Number:
Your answer
Secondary Contact Phone Extension (if applicable):
Your answer
Secondary Contact Email:
Your answer
Secondary URL:
Your answer
Thank you for submitting/updating your information.
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