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PCP SITE IDENTIFICATION FORM Facility Name: DOCS Site ID# (for health plan use only): Address: Site NPI: Site Email Address: IPA Name(s) for Medical Managed Care & Cal Disconnect (CMC) Programs: Telephone:

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How to fill out pcp site identification form

01

Obtain the PCP Site Identification Form from the relevant authorities or website.

02

Fill in the required information such as the site name, address, contact person details, etc.

03

Provide any additional information or documentation that may be required.

04

Review the completed form for accuracy and completeness.

05

Submit the filled out PCP Site Identification Form to the designated office or department.

Who needs pcp site identification form?

01

Organizations or individuals who are establishing or managing a Pollution Control Program (PCP) site.

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What is pcp site identification form?

The pcp site identification form is a document used to report information about a specific site where a primary care physician (PCP) is located.

Who is required to file pcp site identification form?

PCPs and healthcare organizations are required to file the pcp site identification form.

How to fill out pcp site identification form?

The pcp site identification form can be filled out online or in paper format and requires information about the PCP's name, contact information, site location, and practice details.

What is the purpose of pcp site identification form?

The purpose of the pcp site identification form is to provide accurate information about PCP site locations for regulatory and informational purposes.

What information must be reported on pcp site identification form?

Information such as PCP name, contact details, site address, practice name, and practice details must be reported on the pcp site identification form.

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