Provider Business Type
(Required for all business entities/provider types)
- Select one business type from the drop down list.
- If you choose the option ‘Other’, you must provide additional information about the business type in the text box.
Provider Legal Name
(Required for all business entities/provider types)
- Your Organization’s Legal Name is displayed here. It was entered by DSHS.
- This name must be spelled correctly. If there is an error in how the name of your Organization is spelled or represented, contact the CMBHS Help Desk.
Provider Common Name
- TYPE in the name the Provider wants to go by in CMBHS.
Effective Date
- This is the date that your first contract with DSHS became effective or the first date of the fiscal year of your current contract with DSHS.
- Enter the date in the mmddyyyy format. CMBHS will convert the numbers to the correct date format of mm/dd/yyyy automatically.
Expiration Date:
(Required for all business entities/provider types)
- Enter date in mmddyyyy format. CMBHS will convert the numbers to the correct date format of mm/dd/yyyy automatically.
Business Phone
(Required for all business entities/provider types)
- Enter the 10 numbers and CMBHS will be automatically format the numbers into the phone number format.
- Enter as many of these as are available:
- Toll Free Number (Not Required)
- Fax Number (Not Required)
- URL for Website (Not Required)
- Email Address (Not Required)