Request Provider Information Sheet Page

This window allows you to request that a Provider Information Sheet be sent to the address on record for the Medicaid provider.

Provider Information Sheets can only be sent to the address on file with HFS for the provider entered.

You must enter all required fields, and in the correct format. See below for a list of fields and validation rules.

Field Name	Definition	Validation Rules	Field Type
Provider Number	the HFS identification number of the provider for which you want the Provider Information Sheet	Required.	Text Box
Provider Name	the name of the provider for which you want to request the Provider Information Sheet	Required.	Text Box
Provider Address	the address of the provider for which you want to request the Provider Information Sheet	Required.	Text Box
Provider Second Address	the address of the provider for which you want to request the Provider Information Sheet	Not Required.	Text Box
City	the city of the provider for which you want to request the Provider Information Sheet	Required.	Text Box
State	the state of the provider for which you want to request the Provider Information Sheet	Required.	Dropdown Box
ZIP	the ZIP code of the provider for which you want to request the Provider Information Sheet	Required.	Text Box
Your Name	your first and last name	Required.	Text Box
Phone	a phone number where you can be contacted	Required.	Text Box
E-Mail	your e-mail address where you can be contacted if necessary	Required.	Text Box