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Get Dhs 1139 Form 2014-2024

to the Med-QUEST Division’s (MQD) processing of provider applications for the fee-for-service (FFS) program. A list of these requirements is provided below. The MQD is required to obtain a $500 application fee from all providers EXCEPT for Physicians, Psychiatrists, Podiatrists, Optometrists, APRNs, Physician Assistants, RNs, and Dentists. Please submit a money order or cashiers check for $500 when submitting your application, payable to: State Director of Finance c/o Med-QUEST Division Healt.

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