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Exhibit M - Attachment III

PROVIDER INFORMATION FORM MID-LEVEL PROVIDERS

Date:

From:

To: Pearlie Whitfield Provider Relations

Facility/IPA Name:

FAX number: (626) 299-7252

Telephone number: FAX number:

Add Provider to:

Medi-Cal/Temps

CHP Healthy Families Program

IHSS Program

Check and complete all that apply:

Provider Name:

Professional Degree

Physician’s Assistant

Certified Nurse Midwife

List specialty if applicable:

_________________________

Language(s) Spoken by Provider:

  • 1.

    Fluent ________________________

  • 2.

    Fluent ________________________

Intermediate

Intermediate

Nurse Practitioner

3.

Fluent

Intermediate

________________________

4.

Fluent

Intermediate

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

Name of CHP Hospital Affiliation:

Provider Credentialed?

Date last credentialed:

Yes No

_______________________

____________________________

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