DHS-7093A-ENG 11-21 (1.1.1)

BEHAVIORAL HEALTH HOME (BHH) SERVICES

Request to apply for Behavioral Health Home (BHH) services certification

Required field

DHS uses the term "organization" to refer to any medical clinic, community mental health center or other clinic or agency providing primary care and mental health services.

An organization must submit this request to apply in order to begin the BHH services certification process.

What is a BHH ID?

A BHH ID is a password assigned by DHS to MHCP-enrolled providers who want to apply for certification or recertification to provide BHH services. When you submit the information requested below, DHS will send an email to the person your organization has listed as the authorized representative within three business days from the date DHS receives your organization's request to apply.

If you have any questions about the BHH ID, please contact us at dhs.bhh.certification@state.mn.us

For more information about certification requirements, see the BHH services website: http://www.dhs.state.mn.us/dhs16_177945

Request a BHH ID

FULL LEGAL NAME OF THE ORGANIZATION (do not abbreviate)

ADDRESS (street address required, a P.O. Box is not acceptable)

CITY

COUNTY

STATE

ZIP CODE

PHONE NUMBER

FAX NUMBER

ORGANIZATION NPI

FEDERAL TAX ID

Is this location enrolled with MHCP?

Yes

No, I am currently in the process of applying

Who is the person responsible for oversight of the BHH services team operating out of the location identified above?

Does your organization plan to offer BHH services in a location other than the address identified above?

Yes

Locations

Location

ADDRESS (street address required, a P.O. Box is not acceptable)

CITY

COUNTY

STATE

ZIP CODE

PHONE NUMBER

FAX NUMBER

ORGANIZATION NPI

FEDERAL TAX ID

Is this location enrolled with MHCP?

Yes

No, I am currently in the process of applying

Who is the person responsible for oversight of the BHH services team operating out of the location identified above?

Authorized Representative Information

The person must be authorized to accept communication on behalf of the BHH services provider. It is the responsibility of the authorized representative to ensure that all communication received from DHS is distributed to the organization's BHH team as needed, and that the organization provides a response to DHS within stated timelines.

FULL LEGAL NAME (do not abbreviate)

ADDRESS (Street address required, a P.O. Box is not acceptable)

CITY

COUNTY

STATE

ZIP CODE

PHONE NUMBER

FAX NUMBER

EMAIL ADDRESS

DHS Review

New BHH ID (Enter 00000000 if you want to deny this request)

numRows

The entered BHH ID is already in use.

BHH ID is unique.

Request will be denied.

ReviewStatus

GUID