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Provider Practice Information

Required Disclosures

Licensure: Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?
Affiliations: Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (Including HMOs, PPOs, or provider organizations such as IPA’s PHOs)?
Medicare. Medicaid or other Governmental Program Participation: Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs.

Membership Level

Thank you for your submittal!

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