JEREMIAH W. (JAY) NIXON
GOVERNOR
KEITH SCHAFER, Ed.D.
DIRECTOR / STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
1706 EAST ELM STREET
P.O. BOX 687
JEFFERSON CITY, MISSOURI 65102
(573) 751-4122
(573) 751-8224 FAX
www.dmh.mo.gov / MARK STRINGER
DIRECTOR
DIVISIONS OF ALCOHOL& DRUG ABUSE
and
COMPREHENSIVE PSYCHIATRIC SERVICES
(573) 751-9499
(573) 751-7814 FAX
BERNARD SIMONS
DIRECTOR
DIVISION OF
DEVELOPMENTAL DISABILITIES
(573) 751-4054
(573) 751-9207 FAX

An Equal Opportunity Employer; services provided on a nondiscriminatory basis.

Partnership for Hope Dental Contract Application

To request a contract for the provision of dental services to adults with developmental disabilities through the Missouri Partnership for Hope Home and Community-Based Waiver, please complete this application and submit it to the Division of Developmental Disabilities Regional Office in the county where your dental clinic is located. You may accept referrals to treat Partnership for Hope (PfH) waiver participants residing in any county in the PfH service area, regardless of where your office is located.

An application is required for each licensed dentist, and each dentist will be issued an individual contract.

Name of dentist:

Missouri license number:

Dental office address:

Phone number: E-mail:

I am enrolled with MO HealthNet to provide dental services: Yes______No ______

Would also like to enroll directly with MO HealthNet as a PfH waiver provider (contract with state still required)

Yes______No______

If you elect to also enroll with MO HealthNet, the division will provide you with the MO HealthNet provider enrollment forms. You will be issued a MO HealthNet “85” provider-type number, the provide type used for all DD waiver services.

An Equal Opportunity Employer; services provided on a nondiscriminatory basis.