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Get SC Uniform Managed Care Provider Credentialing Application 2005-2024

Urance of an adequate and acceptable amount reflective of your specialty as a prerequisite for participating in a managed care organization. Please attach a copy of your most recent malpractice insurance binder. List current and previous malpractice insurance carrier(s) for past five years: CARRIER NAME/ADDRESS VI. POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE AMOUNT OF COVERAGE Five Year Work History (CV can not be used in lieu of completing this section) NAME OF PREVIOUS/CURRENT EMPLOYER(.

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