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Provider Practice Information
Provider First Name
Provider Contact Email Address
Clinic Address
Clinic State
Office Phone Number
Mobile Phone Number
Provider Last Name
Practice Name
Clinic City
Clinic Postal Code
Office Email Address
Website URL
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?
Yes
No
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)?
Yes
No
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.
Yes
No
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