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These pdf forms are provided for your convenience. If you have any questions, call us at (828) 670-9145.
EMPLOYEES
Employee Request for Physician Participation in Crescent Preferred Provider Network
PHYSICIAN PROVIDER APPLICATION FORMS
Credentialing
Application
Participating
Physician Agreement
Exhibit
D - Antitrust Policy
Exhibit
D - Guidelines
Physician
Fee Submission Form
Physician
Provider Checklist
IRS
W-9 Form
Contract amendment
for Fully Insured products
ALLIED PROFESSIONALS APPLICATION FORMS
Credentialing
Application
Allied
Health Provider Agreement
Exhibit
D - Antitrust Policy
Exhibit
D - Guidelines
Physician
Fee Submission Form
Allied
Provider Checklist
IRS
W-9 Form
Contract amendment
for Fully Insured products
FACILITY/HOSPITAL APPLICATION FORMS
Participating
Facility Agreement
Insurer Amendment - Participating Facility Agreement
Participating
Hospital Agreement
Insurer Amendment - Participating Hospital Agreement
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Crescent
PPO 1200 Ridgefield Blvd., Suite 215 Asheville, NC 28806 Phone:
828-670-9145
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