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Provider Contact Information Collection Survey
*
1.
Name:
(Required.)
First:
Last:
*
2.
Please check the title below that best represents your job responsibilities:
(Required.)
Practice Manager
Billing/Business Office Manager
HealthCheck Coordinator
Other (please specify)
*
3.
E-mail Address:
(Required.)
*
4.
Practice Name:
(Required.)
*
5.
Practice Address:
(Required.)
Street:
City:
ZIP:
*
6.
Practice Phone Number (include area code):
(Required.)
7.
How do you prefer to receive information from Security Health Plan? (check all that apply)
Phone
E-mail
Mailings
Online Portal
Other (please specify)
