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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
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