Enrollment Process for Providers

Providers who wish to enroll as a PrimeWest Health network provider must complete, sign, and return a PrimeWest Health Provider Participation Agreement, Participation Request form, and, for practitioners for whom credentialing is required, applicable credentialing forms. The Provider Participation Agreement includes a statement of terms for participation. To request a contract with PrimeWest Health, interested parties should complete a Participation Request form.

The Participation Request form will be reviewed by PrimeWest Health staff and a decision will be made as to whether PrimeWest Health will proceed with a contract. The listed contact person will be notified of the decision. If the request is approved, the contract is not executed until the contracting and practitioner credentialing processes, if applicable, are complete.

Please note, submitting the Participation Request form does not guarantee approval as a PrimeWest Health network provider.

PrimeWest Health Contracting Forms and Documents

PrimeWest Health Enrollment Forms

  1. Home and Community Based Waivered Services Provider Enrollment Application
  2. Request for Taxpayer Identification Number and Certification (W-9) form
  3. Home and Community Based Service Providers Criminal Background Check Verification List – as applicable
  4. Disclosure of Ownership and Control Interest of an Entity

Assurance Statements

  1. Adult Day Services Providers Applicant Assurance Statement
  2. Adult Companion Services Providers Applicant Assurance Statement
  3. Assistive Technology Providers Applicant Assurance Statement
  4. HCBS Lead Agency Provider Enrollment Request Form
  5. Chore Service Providers Applicant Assurance Statement
  6. Customized Living Providers Applicant Assurance Statement
  7. Elderly Waiver/Alternative Care (EW/AC) Family Caregiver Training and Education Providers Applicant Assurance Statement
  8. Environmental Accessibility Providers Applicant Assurance Statement
  9. Family Training and Counseling Providers Applicant Assurance Statement
  10. Home Delivered Meals Providers Applicant Assurance Statement
  11. Homemaker Providers Applicant Assurance Statement
  12. Personal Emergency Response System Providers Applicant Assurance Statement
  13. Provider Assurance Statement for Telemedicine
  14. Specialized Supplies and Equipment Providers Applicant Assurance Statement
  15. Transitional Service Providers Applicant Assurance Statement
  16. Waiver Transportation Providers Applicant Assurance Statement

Minnesota Department of Human Services (DHS) Forms and Documents

  1. Service Request Form for HCBS Waiver, Alternative Care (AC), Moving Home Minnesota or Essential Community Supports (DHS-6638)
  2. Waiver and Alternative Care (AC) Programs – Provider Enrollment Application (DHS-4015)
  3. Minnesota Health Care Programs (MHCP) Provider Agreement (DHS-4138)
  4. Lead Agency Provider Enrollment Request Form (DHS-6383)
  5. Provider Not Required to Receive a 245D Program License Applicant Assurance Statement
    (DHS-6189Z)
  6. Disclosure of Ownership and Control Interest of an Entity (DHS-5259)
  7. Designation of HCBS Waiver or AC Program Billing Person (DHS-6855)
  8. Supported Employment Service Providers – Moving Home Minnesota – Applicant Assurance Statement (DHS-3873)

Change of Enrollment Information

PrimeWest Health Provider Network Administration must be notified in writing no later than 45 days before the effective date of any change of information regarding the provider’s facility provided on the Participation Request form.

To notify PrimeWest Health of any changes, send a written notification signed by the person who executed the contract with PrimeWest Health and mail to:

Attn: Contracting
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

This notification may also be sent via email to contracting@primewest.org.

In addition to the written notification, complete/update the pages of the Participation Request form that reflect the current changes to your facility.

PW_03-18_091
Updated_08/15/2025