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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

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.




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Other Information

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City* State* Zip*
County*

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