Specialist Application

We invite you to join PBACO’s High Caliber Network (HCN) and share your expertise to help us betterunderstand the range of care options available to our patients. This application combinesadministrative/practice details with in-depth questions about your specialization and approach to care.Completion should take approximately 20-30 minutes.

PRACTICE AND ADMINISTRATIVE INFORMATION

Practice Name:

Specialty:(If multispecialty, please indicate)

Practice Addresses/es:(Please indicate if multiple)

Billing Address:(if different)

Practice Phone Number:

Fax Number

Tax ID Owner/s Name:

Tax ID Number:

Tax ID Owner Email & Cell:

Practice NPI Number:

PROVIDER DETAILS

Please fill out for each NPI/provider in the practice you’d like included as an Affiliate Member.

Provider 1

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Provider 2

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Provider 3

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Provider 4

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Provider 5

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MEDICAL SPECIALIZATION AND SERVICES PROVIDED

Are you a subspecialist? If so, please specify:

COLLABORATION AND REFERRALS

What is your preferred method of communication with other providers? (EMR, cell phone, etc.):

Which medical specialties do you commonly refer patients to when their conditions requirespecialized attention beyond your expertise?

What is your referral workflow for receiving patients?

How soon do you schedule new patients?

ADDITIONAL INFORMATION

If there's anything else you would like to share about your practice or services, please do so here:

SIGNATURE

This application collects information to support PBACO's physician-led, value-based care mission.
Submission indicates your interest in joining the High Caliber Network.
Data will be handled confidentially per PBACO policies.

Name of signee:

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Specialist Application

PRACTICE AND ADMINISTRATIVE INFORMATION

PROVIDER DETAILS

Provider 1

Provider 2

Provider 3

Provider 4

Provider 5

PRACTICE MAKE-UP

MEDICAL SPECIALIZATION AND SERVICES PROVIDED

COLLABORATION AND REFERRALS

ADDITIONAL INFORMATION

SIGNATURE

What to Expect

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