Primary Care Provider Results and Recognition Contact Form

Information needed to communicate and process incentive payments.

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* 1. Practice name:

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* 2. Main contact name

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* 3. Address for check to be sent:

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* 4. Service Address (please complete if not the same as above):

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* 5. Tax ID:

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* 6. Fax number:

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* 7. Which means of communication is preferred?  Check all that apply

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* 8. Practice information:

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* 9. Are you enrolled in EFT for payments?

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