Information Request Form NOTE: Please note that this is not an application. Providers are not credentialed using this form. Please be sure to complete all information. Incomplete forms can not be processed. Coordinated Medical Specialists and Coordinated Podiatry Networks assesses all requests based on network needs in specific geographic location. Based on network needs in your area, Coordinated Medical Specialists and Coordinated Podiatry Networks may forward an application package to your practice. Please be aware that returning a completed application is not a guarantee that your practice will be added to the network. In the event that the network is closed in your Area at the time of your request, your Provider Application Request Form will remain on file. ALLOW 30 DAYS FOR A RESPONSE Contact person for application and credentialing: How many Providers are in the Practice? How many Locations are in the Practice? Name of all Providers in the practice (to add more, click "List More Providers" below): 1 Name: Degree: Does provider have a... CAQH#?:   Y    N  NPI#?:   Y    N  Medicare #:   Y    N  Medicaid #:   Y    N  Is the provider willing to visit Skilled Nursing Facilities? Y   N  Up to:    miles Is the provider willing to visit Assisted Living Facilities? Y   N  Up to:    miles

Name of all Locations (to add more, click "List More Locations" below):

Location #1:

Practice Name:
Address:
City:
State:
Zip:
County:
Phone:
Fax:
Email:
Tax ID Number:

Notes:

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7352 NW 34th Street - Miami, Fl 33122 - 877-253-8734 - Fax 954-208-6903
www.Coordinated-Podiatry-Networks.org