Request New/Update Existing Essential Health Provider

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This form is designed to 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/2022/04/2023-MHBE-Essential-Community-Health-Providers.xlsx

Email *

MHBE Number: *

Please reference the current ECP list to find your MHBE reference number: https://www.marylandhbe.com/wp-content/uploads/2022/04/2023-MHBE-Essential-Community-Health-Providers.xlsx

Site name where medical services are provided: *

Organization Name *

National Provider Identifier (if available, otherwise blank):

Select your ECP Type: *

Hospital

Federally Qualified Health Center

Ryan White Medical Provider

Indian Provider

Other

2018 Expansion Provider (2016 Expansion Providers are defined by 45 CFR § 156.235(c) as: local health departments, outpatient mental health centers, substance use disorder treatment providers (as described by COMAR 10.09.80.03.B(1) & B(3)) that are licensed or approved by MDH as a program or facility, or school-based health centers.)

Required

Site Street Address: *

Site City: *

Site Zip Code: *

Site County: *

Organization Street Address: *

Organization City: *

Organization Zip Code: *

Organization County: *

Primary Contact Name: *

Primary Contact Title: *

Primary Contact Phone Number: *

Primary Contact Phone Extension (if applicable):

Primary Contact Email Address: *

URL:

Secondary Contact Name:

Secondary Contact Title:

Secondary Contact Phone Number:

Secondary Contact Phone Extension (if applicable):

Secondary Contact Email:

Secondary URL:

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