• Settlement Agreement(current)
  • MAF Physician Locator(current)
  • Report Fraud
  • Key Dates
  • Register
  • Home (current)
  • Forms
    Payment Claims Centralized Process for Representative Appointment Registration Attorneys’ Fee Dispute Other
  • Governing Documents
    Governing Rules Governing Decisions Norming Agreement Court Orders & Opinions Settlement Agreement
  • Useful Information
    Reference Guides Status Reports Alerts Newsletters Class Notice Materials Opt Out Information
  • FAQs
    View All FAQsRecently UpdatedBasic InformationSettlement Agreement Benefits - General InformationRegistrationBaseline Assessment ProgramMonetary AwardsRepresentative ClaimantsDerivative ClaimantsLawyersLiens - Information for Settlement Class MembersLiens - Information for LienholdersPaymentsAuditBankruptcyAppealsExternal EvidenceSpecial Master Appeal DecisionsNorming Agreement
  • Reports & Statistics
  • MDL 2323 Docket
  • Contact & Help
  • Login

NETWORK PROVIDER APPLICATION

Please complete and return this application with the following supporting documents:

  • A copy of your state license to operate;
  • Certificate(s) of Insurance proving current general liability and professional liability/medical malpractice insurance coverage and amounts of coverage;
  • A copy of your organization’s W-9 form (most recent IRS version); and
  • If you or any of the facilities or practice sites in your system participate in one or more state-sponsored or state-affiliated patient compensation funds, please include (a) the name of the fund(s), (b) a list of your service or practice sites participating in each such fund, (c) your certificate(s) of coverage, and (d) the declaration page(s) for your underlying primary coverage(s), general and professional liability.
  • Please also attach a current curriculum vitae for each proposed practitioner.

Note: If you require more space than is provided by any of the boxes on this form, please submit additional pages as needed.

Retrieve Your Application

Please enter your Application ID and registered email address to retrieve your application. A verification code will be sent to your registered email to confirm your identity.

Application ID:
Email:
Send Verification Code Clear
Upload Document

Click the Browse button to navigate to the file location on your local network. You can upload an Adobe PDF file.

Document Type: 
Upload Document: 
Submit
Confirmation
Your unsaved changes will be lost. Are you sure you want to continue?
Yes
Verify Address
Recommeneded Address
User entered Address
Cancel