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Get Affinityplan Health Participation Request Form

Participation Request / CAQH Form Date Complete the Participation Request form and fax to our office at 718-794-7808 for evaluation for participation into the Affinity Health Plan Provider Network. Once your request is reviewed for network need you will be notified either by mail or by an Affinity Health Plan Provider Relations Representative. Please print clearly Provider Last Name First MI Degree Date of Birth Gender M F NYS Lic TIN Contract Ty.

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