Application Packet

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• Physician and Allied Health Providers
  • Application for Network Participation
    • Cover Letter
    • Instruction Sheet
    • Application for Network Participation
  • W-9 Form(Must complete W-9 for each TAX ID listed on application)
    • W-9 Form
  • Statement of Collaboration Form
    • Statement of Collaboration Form
  • Alternate Hospital Coverage Letter
    • Hospital Coverage Letter
  • Provider Network Participation Agreements (Physician Only)
    • Instruction Sheet - Provider Network Participation Agreement
    • QualCare Provider Network Participation Agreement
    • QualCare HMO/POS Network Addendum
    • QualCare Workers' Compensation Product Addendum
    • QualCare Patient Centered Medical Home Supplement to HMO/POS Network Addendum Agreement
  • Individual Allied Health Practitioner Network Participation Agreements (DC, APN, PA, OD, RD and All Behavior Health Providers Only)
    • Instruction Sheet - Provider Network Participation Agreement
    • QualCare Provider Network Participation Agreement
    • QualCare HMO/POS Network Addendum
    • QualCare Workers' Compensation Product Addendum
  • QualCare's Hospital Network Directory
    • QualCare's Hospital Network Directory