Request New/Update Existing Essential Health Provider
This form is designed to allow current ECPs to update their information. For your reference, the most recent ECP list can be found here:
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Email *
MHBE Number: *
Please reference the current ECP list to find your MHBE reference number:
Site name where medical services are provided: *
Organization Name *
National Provider Identifier (if available, otherwise blank):
Select your ECP Type: *
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: *
Secondary Contact Name:
Secondary Contact Title:
Secondary Contact Phone Number:
Secondary Contact Phone Extension (if applicable):
Secondary Contact Email:
Secondary URL:
Thank you for submitting/updating your information.
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