Get Community Care Physicians Network Acknowledgement Form

Filling out the Community Care Physicians Network Acknowledgement Form online is a straightforward process designed to streamline your participation in the EverMed Direct Primary Care network. This guide provides clear, step-by-step instructions to ensure that users of all experience levels can complete the form with ease.

Follow the steps to complete the acknowledgment form online.

1. Click the ‘Get Form’ button to access the Community Care Physicians Network Acknowledgement Form and open it in your online editor.
2. Begin by filling in the 'Practice Name' field with the official name of your medical practice.
3. In the 'Practice Representative Name' section, enter the name of the individual authorized to sign the form on behalf of the practice.
4. Provide the 'Practice Rep. Signature' by affixing an electronic signature or typing in the name of the representative to validate the document.
5. Fill in the 'Phone Number' and 'Email Address' fields to ensure proper communication regarding your practice's participation.
6. Record the current date in the 'Date' field, indicating when the form is being completed.
7. Indicate your practice's capacity for accepting new EverMed patients by selecting one of the provided options related to the number of new patients.
8. If your practice has multiple locations, use the 'Multiple Practice Location Capacity Table' to provide details for each location, including the number of new patients accepted.
9. Review the 'Included Services' section to ensure you understand the services that are covered under the contract, and acknowledge the enrollment conditions.
10. Once all fields are completed accurately, save your changes, and proceed to download, print, or share the form as needed.

Complete your Community Care Physicians Network Acknowledgement Form online today to facilitate your practice's participation in the EverMed DPC network.