First Name
Last Name
GenderMaleFemale Medical Designation (Please select one option below)
MDDOPANOther
NPI Number
Specialty
Are you board certified in this specialty?YesNo Does your NPI profile reflect the correct taxonomy code to support your specialty?YesNo
Practice / Facility Name Address
City
State
Zip Code
Phone Number
Fax Number
Office Hours
Are you part of a group practice? YesNo
If so, please provide the following:
Group Name Address
Who within the group has binding signatory authority for provider contracts?
Name
Title
Email
If you are a Single Practice/Provider, is any staff member in your office, including Office Manager, or anyone else, authorized to act as your agent to sign contracts for you or on your behalfYesNo
If yes, what is the authorized agent's name and title?
Do you authorize this agent to negotiate contract rates on your behalf? YesNo
If Group Practice, do you have binding authority to sign contracts for or on behalf of the group?YesNo
If no, who has authority within the Group Practice to sign contracts as the agent for or on behalf of the group?
Authorized agent's name and title?
I acknowledge that any named person identified on this form as my agent has full authority to act as my agent, or in the case of a group, the group's agent, to negotiate rates; and has signatory authorization for or on my behalf to contractually bind me, or in the case of a group, contractually bind the group. I understand the decision to extend a contract to join the Network is the sole discretion of Seva Care representatives whose decision is final.
Date
