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Are you registering this clinic for the first time or is the an update to a previous registration?
Select One:
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Please enter clinic information below:
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Contact Person:
Contact Person's Title:
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Medical Director or Supervisor:
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Enter time when clinic OPENS for each day of operation:
 HH MMAM/PM
Sunday: 
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Monday: 
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Tuesday: 
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Wednesday: 
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Thursday: 
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Friday: 
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Saturday: 
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Enter time when clinic CLOSES for each day of operation:
 HH MMAM/PM
Sunday: 
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Monday: 
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Tuesday: 
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Wednesday: 
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Thursday: 
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Friday: 
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Saturday: 
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Providers
Other Licensed or Certified Providers: Please list type and number below
Specialist Providers: Please list name, specialty, and location for each provider.
Provider Application Information:
Applications for your providers may only be obtained through your organization. Please provide this application to your provider(s) and have them return it to your organization. If your provider refers to a specialist physician in a private practice setting, please determine if that physician requests participation in this program. If so, please forward an application to that physician and list his/her name and specialty above.
If you have any questions, please call the Office of Primary Care at (405) 271-8427.

Please forward the completed Provider Application to
Oklahoma State Department of Health
Community Development Service: Rm. 511
ATTN: Volunteer Health Care Provider Program
1000 N.E. 10th Street
Oklahoma City, OK 73117
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