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AMERIGROUP Washington, Inc Letter of Intent Provider  Form

AMERIGROUP Washington, Inc Letter of Intent Provider Form

Use a amerigroup washington 0 template to make your document workflow more streamlined.

Y or N Website Address Section II Practitioner Information and Professional IDs if applicable to Provider Type Last Name First Name Middle Initial Council for Affordable Quality Healthcare CAQH ID if applicable Section III Professional/Medical Specialty information Primary Specialty Secondary Specialties Professional Degree Limits e.g. age adults only Languages other than English Provider Provides Obstetrical Care Yes No Provider is PCP Only SCP Only Both PCP Panel Status Open Yes No Accepts...
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