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.