dch-1401, electronic signature agreement

Michigan Department of Health and Human Services

(Revised 2-22)

section 1

Employer or Employing Entity Name	Employer Identification Number	NPI

Individual Name (Doctor, Dentist, Nurse, etc.)	NPI

section 2

The undersigned Individual and Employing Entity attest that they have entered into an agreement effective on the date indicated below. Both parties agree an authorized representative of the Employing Entity has the authority to sign and submit the electronic Michigan Department of Health and Human Services Medical Assistance Provider Enrollment Trading Partner Agreement and to maintain enrollment information through the MDHHS CHAMPS Provider Enrollment Subsystem. Both parties also agree that the Employing Entity listed above is liable and bound by all information submitted on his or her behalf as if the Employing Entity had submitted changes to CHAMPS directly.

Individual Signature	Date

Employing Entity Signature	Date

Individual MILogin User ID	Date

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.