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This document serves as the signature page for the Blue Cross Complete of Michigan Practitioner Group Affiliation Agreement, detailing the acknowledgment of terms by the Provider and the Health Plan.
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How to fill out practitioner group affiliation agreement
How to fill out Practitioner Group Affiliation Agreement Signature Page
01
Begin by reviewing the agreement document to understand the terms and conditions.
02
Locate the Practitioner Group Affiliation Agreement Signature Page.
03
Fill in the name of the practitioner in the designated field.
04
Include the name of the group or organization with which the practitioner is affiliated.
05
Add any required identification numbers or credentials, if applicable.
06
Ensure the date of signing is accurately entered.
07
Have the practitioner sign in the provided signature box.
08
If required, include contact information such as phone number and email address.
09
If applicable, ensure that any witnesses or additional signatories sign as well.
Who needs Practitioner Group Affiliation Agreement Signature Page?
01
Practitioners who are joining a healthcare group or organization.
02
Healthcare organizations that require formal agreements with affiliated practitioners.
03
Legal and compliance teams overseeing agreements within healthcare entities.
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What is Practitioner Group Affiliation Agreement Signature Page?
The Practitioner Group Affiliation Agreement Signature Page is a document that signifies the agreement between a healthcare practitioner and a group or organization, confirming the practitioner's affiliation with that group.
Who is required to file Practitioner Group Affiliation Agreement Signature Page?
Healthcare practitioners who are joining or are affiliated with a group or organization are required to file the Practitioner Group Affiliation Agreement Signature Page.
How to fill out Practitioner Group Affiliation Agreement Signature Page?
To fill out the Practitioner Group Affiliation Agreement Signature Page, practitioners should provide their personal details, affiliation details with the group, and sign the document to indicate their acceptance of the terms.
What is the purpose of Practitioner Group Affiliation Agreement Signature Page?
The purpose of the Practitioner Group Affiliation Agreement Signature Page is to formalize the relationship between the practitioner and the group, ensuring clarity regarding roles, responsibilities, and obligations.
What information must be reported on Practitioner Group Affiliation Agreement Signature Page?
The information that must be reported includes the practitioner's name, contact information, the group's name, terms of affiliation, and any specific conditions or agreements pertinent to the affiliation.
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