New Contract Inquiry Form

Please complete this form if your organization is interested in providing services to members of Detroit Wayne Integrated Health Network. Note: Fields with a red asterisk (*) are required fields. Complete the form in its entirety and click Submit.

STOP! Please return to the website to read the Contract Checklist.

Do Not Click Submit. Return to the Provider Inquiry page on the Detroit Wayne website www.dwihn.org to view provider requirements. Thank you.

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STOP!! PLEASE CONTACT YOUR PROVIDER NETWORK MANAGER/CONTRACT MANAGER

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STOP! Per Contract Requirements Insurance is required. See Contract Checklist.

All Requirements have not been met your form will not be reviewed.

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STOP! All Contract Requirements Must Be Met Before Continuing

See Checklist for a list of requirements. All Requirements have not been met your form will not be reviewed.

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Tell Us About Your Organization

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Include the Number and Street Name

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Upload any provider brochures or pamphlet for your organization in the space at the bottom of the form.

Residential Home Living

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Are you willing to accept 18 years old and up?

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Members may be engaged with work, school, or may have scheduled appointments. Do you have adequate staffing and vehicles to ensure members have access to their commitments?

Staff will be expected to follow and implement interventions directed by the member’s IPOS and/or behavior treatment plan

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Don't have a NPI #. Register for free at nppes.cms.hhs.gov/webhelp/nppeshelp/MAIN PAGE.html

Tell Us About Your Service(s)

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Current Program Information

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Behavioral Health and Intellectual Developmental Disability Support Services. Please refer to the Medicaid Manual for provider service details. https://www.michigan.gov/mdhhs/0,5885,7-339-71551_2945_42542_42543_42546_42553-87572--,00.html

NOTE: Services with an asterisk (*) must be approved by MDHHS and is required to have either a license/permit or registration to perform the services.

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This form is to be completed on all individuals/organizations requesting information on becoming a network provider.

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Yes, staff are training in following: Select all that apply

No, staff is not trained but are willing to be trained in the following:

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Provide the number of staff and explanation below:

For more information or to register, please visit SAM.GOV to register for free.

www.sam.gov