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Specialty Networks
Thank you for your interest in becoming a provider. Please fill out the form with as much information as possible and submit online.
Referring Party Information
Entity name
Contact name
Responsible for network contracting
Same as above
Other
Address
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Phone
Fax
Email
Tax ID#
I am interested in the following:
Behavioral Health
Pain Management
Post-Acute Care
Ortho & Spine Care
Other
My practice accepts:
Medicare
Workers' Compensation
Group Health
Liability
PIP
Other
Additional Information
Does you practice currently participate in any other network?
Yes
No
What % of your practice is devoted to seeing Medicare patients?
What % of your practice is devoted to seeing Workers' Compensation patients?
Does your practice self-dispense prescription medications? (if applicable)
Yes
No
Does your practice offer a Functional Restoration Program (FRP)?
Yes
No
Are you certified in Progressive Goal Attainment Program (PGAP)?
Yes
No
Is your practice currently accepting new patients?
Yes
No
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