Please fill out the required fields and an MHA Representative will contact you shortly regarding membership.  * Required Fields

Facility Name:*
Address:*
City:*
State:*
Zip:*
Phone:*
Fax:
Contact Name:*
Contact Title:*
Contact E-Mail:*
DEA Number:*
HIN Number:*
Federal Tax Number:*
State Tax ID Number:*
LTC Provider Home Infusion Provider
Closed Door Closed Door
Combo w/ Separate DEA Combo w/ Separate DEA
Combo w/o Separate DEA Combo w/o Separate DEA
Hospital
General Acute Care Staff Model HMO
Rehabilitation and Chronic Disease Ambulatory Surgical Group
Psychiatric Hospital Mail Order
Special Acute Care Medical/Surgical Only

Other: 
MHA Programs Information (Adobe PDF) coming soon
MHA WebTools Information (Adobe PDF)
MHA Membership Agreement (Adobe PDF)
 **This is a sample agreement.  Upon completion an applicant can mail or fax this form to MHA and a representative will contact you regarding membership.
Click here to request the full membership packet by mail