Facility Application Request

To be completed by organizations that offer inpatient, partial hospitalization, and intensive outpatient services.

If you provide outpatient services only, please complete either an individual practiotioner application or a group practice application .

Questions should be directed to MHC Provider Relations at 215-343-8987.

Facility Application Request
Requestor's Name
Requestor's Name
Title
First
Last
Is your facility under ownership of another organization?
Please check off all of the states in which your facility and/or organization is located in and/or affiliated or associated with
Is your facility licensed?
How many years has your facility been licensed?
Is your facility accredited or certified?
Please list type of accreditations and/or certifications
Check All That Apply
What services do you offer at your facility?