Letter of Intent

Date
Invalid Input

Physician/Practitioner Name(*)
Please enter Physician/Practitioner Name

Contact Name
Please enter Contact Name

Office Address
Invalid Input

Billing Address
Invalid Input

City, State, Zip
Invalid Input

City, State, Zip
Invalid Input

Telephone
Invalid Input

Telephone
Invalid Input

Fax
Invalid Input

Fax
Invalid Input

E-mail
Invalid Input

E-mail
Invalid Input

Practice Name
Invalid Input

Office Hours
Invalid Input

Electronic (EDI) Claims Clearinghouse
Invalid Input

EHR System
(if applicable)
Invalid Input


ABMS Certification Status:

Board Certified
Invalid Input

Non Board Certified
Invalid Input

Board Eligible
Invalid Input

Date of Scheduled Exam
Invalid Input

Specialized Pediatric Training
Invalid Input

Medicare enrollment #
Invalid Input

 
Medi-Cal
enrollment #
Invalid Input

Provider transaction access #
Invalid Input

 

National Provider Identification Number (NPI):

Individual
Invalid Input

Group
Invalid Input

My Current Curriculum Vitae (C.V.) will be:
Invalid Input


As a provider with Monarch HealthCare, I would provide service to HMO AND
(Select any of the following):



Invalid Input

Have you ever been a Monarch HealthCare Provider in the past?
Invalid Input

My primary specialty is:
Invalid Input

My secondary specialty is:
Invalid Input

The language(s) I speak:
Invalid Input

The language(s) my office staff speak:
Invalid Input

My Outpatient Surgery Center affiliation(s) is/are:
Invalid Input

I have ownership in the following Outpatient Surgery Center(s):
Invalid Input

I have Hospital Privileges at



Invalid Input