Contracting Forms

Disclosure of Ownership and Control Interest 
Providers must fill out this form to disclose any ownership or controlling interest in contracted facilities.

Facility Change/Update Form 
Providers should use this form to submit demographic changes for their facility.

Home and Community Based Service Providers Criminal Background Check Verification List 
Providers should use this document to enroll with PrimeWest Health to provide Home and Community Based Elderly Waiver (EW) services.

Home and Community Based Waivered Services Provider Enrollment Application 
Providers should use this document to enroll with PrimeWest Health to provide Home and Community Based Elderly Waiver (EW) services.

Internal Revenue Service W-9 
This form is required for all providers billing PrimeWest Health for services rendered 

Minnesota Uniform Facility Credentialing Application 
Providers should use this form to submit information about their organization during the PrimeWest Health contracting/credentialing process. 

Non-Emergency Medical Transportation (NEMT) Provider Questionnaire
NEMT providers should use this form to provide PrimeWest Health with information about their documentation and systems.

Practitioner NPI/UMPI Notification/Request Form 
This form is used to verify and register a provider with the State of Minnesota 

Participation Request Form 
Providers who wish to contract with PrimeWest Health should complete this form. 

Personal Care Assistance (PCA) Agency 
Form for PCA providers to use when designating PCA billing staff. PrimeWest Health's version of DHS-6005-ENG. 

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Updated_01/13/2026