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2009 Physician Referral Service Application DRAFT TEST ONLY

DRAFT ONLY.

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Middle Initial
Last Name *
Email
Organization *
Street *
City *
State *
Zip *
Phone *

1.
Facsimile number:
2.
Cellular number:
3.
Pager number:
4. *
Preferred method of contact:
5. *
Specialty:
6. *
Sub specialty:
Instruction Important: Practice Specifications
7. *
Are you part of a group practice?
 
 
8.
Practice name:
9.
Hours of operation:
10.
Practice phone number:
11. *
Do you accept minors?
 
 
12.
If yes, ages accepted:
13.
Languages other than English that you or your office personnel speak:

If Other, please specify:

14.
Additional information or instructions:
Instruction Primary office location
15. *
Street address:
16. *
City:
17. *
State:
18. *
Zip code:
19. *
Phone:
20. *
Facsimile:
21. *
Office manager:
Instruction Secondary office location
22.
Street address:
23.
City:
24.
State:
25.
Zip code:
26.
Phone:
27.
Facsimile:
28.
Office manager:
Instruction Accepted Insurance Programs
29. *
Listed below are the insurances accepted by our hospital facilities. Please select from the list below the insurance plans that currently are accepted by your practice.
30. *
I understand to be included in the Physician Referral Program, I must be able to see patients within 2 weeks and provide updated practice information biannually and as needed. I understand that my clinical interests will be assigned based on practicing specialty types and subtypes. Additional priviledges for specialized procedures will be assigned by medical affairs and will require VPMA approval.
 
 
31. *
Type initials below:

Authentication *
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