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  • More about us

Downloads

Initial Information Request Form (pdf)

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Additional information needed

 

In addition to the information packet provided above, we kindly request copies of the following documents:

  1. Current liability insurance
  2. Licenses
  3. Diploma
  4. Resume (if applying for commercial plans)

These documents are essential for completing the credentialing process efficiently and accurately. Thank you for your cooperation in providing these materials.

 The email above and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to which they are addressed. This communication may contain material protected by HIPAA legislation (45 CFR, Parts 160 & 164). If you are not the intended recipient or the person responsible for delivering this email to the intended recipient, be advised that you have received this email in error and that any use, dissemination, forwarding, printing or copying of this email is strictly prohibited. If you have received this email in error, please notify the sender by replying to this email and then delete the email from your computer. 

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