Health Care Homes

Letter of Intent Access Request

Request for access to letter of intent system.

The applicant for certification is the organization. The applicant name should be the broad legal organization name

1. Please specify the applicant name in the intent statement below.*

This letter signifies that intends to apply for certification for health care homes to the Minnesota Department of Health, pursuant to Minnesota Statutes 256B.0751-256B.0754 and Minnesota Rules Chapter 4764.

My Organization is not listed

Primary Contact Information:*

First Name:*

Middle Initial:

Last Name:*

Suffix:

Job Title:

Email:*

Other Information

Address*

City*

State*

Zip*

County*
Telephone Primary*	(ex. 6512015421)
Telephone Secondary	(ex. 6512015400)
Fax	(ex. 6512158951)
Website

Primary Contact Information: Additional Information: Note: The text box above will accept a maximum of 200 characters.

Desired Username:
(if you leave blank, a username will be assigned by the Department of Health.)

Enter the summation of numbers displayed*