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Let us know when your information changes so that we may update our system. Please allow five business days for the change to reflect in our system.  

This form is intended for use by established contracted groups. If you are interested in contracting with us, let us know you’d like to join our network.

Additional documentation (such as W-9s) can be faxed to Provider Services at 541-768-9364.

If you have questions about this form, please call Provider Services at 541-768-5207 or 1-888-435-2396, 8 a.m. to 6 p.m., Mon.–Fri.

Note: All provider and demographic changes must be reported to us within 30 days.

 

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PCP Attestation for InterCommunity Health Network CCO

Do  you need to attest that you meet the criteria for CMS PCP qualification status, as defined in the ACA Section 1202? Instructions are included on the form.