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Exhibit M - Attachment I

Date:

From:

To: Pearlie Whitfield Provider Relations

Facility/IPA Name:

Telephone Number: (626) 299-7251

FAX Number: (626) 299-5512

PROVIDER INFORMATION FORM PLEASE COMPLETE ALL FIELDS ON BOTH PAGES, IF APPLICABLE

Family Practice

Internal Medicine

Pediatrics

OB/GYN

Board Certified?

Board Certified?

Board Certified?

Board Certified

Yes

Yes

Yes

Yes

No

No

No

No

Add Provider to:

CHP Medi-Cal

CHP Healthy Families Program

PASC-SEIU Homecare Workers

Professional Degree

Check and complete all that apply: Provider Name:

Primary Care Provider

General Practice Board Certified?

Yes No

Clinic Site Status

Specialist

Federally Qualified Health Center (FQHC) Primary Care Clinic (PCC)

Community Clinic (CC) Rural Health Clinic (RHC)

List Specialty(ies)

1.

2.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Board Certified?

Board Certified?

Yes

No

Yes

No

____________________________

  • 3.

    Board Certified? ____________________________

  • 4.

    Board Certified? ____________________________

Yes

No

Yes

No

Board Eligibile?

Yes

Board Eligibile?

Yes

Board Eligibile?

Yes

Board Eligibile?

Yes

DHS Facility (DHS)

No

No

No

No

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