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Get CA Participating Physician Application Addendum A 1997-2021

FYING INFORMATION Last Name: First: Middle: Medical Group (s) /IPA(s) Affiliation: Do you intend to serve as a primary care provider? Do you intend to serve as a specialist? Please check all that apply: Solo Practice Group Practice Yes Yes No No (If yes, please list specialty(s)) Single Specialty Multi specialty II. BILLING INFORMATION Billing Company: Street Address: City: State: Contact: Telephone Number: ( Name Affiliated with Tax ID Number: ZIP: ) Federal Tax ID Number: III. PRA.

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