NM High-Fidelity Wraparound Provider Application
Prior to submitting this application, you should have completed the Provider Interest Form and met with a NM High-Fidelity Wraparound Coordinator.
If you’ve not completed the Provider Interest Form, please return to the Wraparound Provider Application Page and do so.
If you are need of the Provider Application Form- Word Fillable Form, please contact Bob Brazell at [email protected] to receive a copy.
Please be prepared to upload these documents. Then complete the application form below.
Provider Application Checklist:
- Completed Provider Application Form- Word Fillable Form
- Most Recent Financial Audit
- Most Recent Profit/Loss Statement
- Organizational Chart
- Internal Agency Policy/Procedures(Optional)