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California Participating Physician Application - MDI

California Participating Physician Application Addendum A - 05/97 Page 1 of 3 Physician Name: CONFIDENTIAL/PROPRIETARY California Participating Physician Application Addendum A Health Plans and IPA s/Medical Groups This Addendum is submitted to:MDI herein, this Healthcare Organization. 1 I. IDENTIFYING INFORMATION Last Name: First: Middle: Medical Group (s) /IPA(s) Affiliation: Do you intend to serve as a primary care provider? Yes No Do you intend to serve as a specialist?

California Participating Physician Application Addendum A - 05/97 Page 2 of 3 Physician Name: Are you a Certified Qualified Medical Examiner (QME) of the State Industrial Medical Council?

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CONFIDENTIAL/PROPRIETARY California Participating ...

www.mdidocs.com

California Participating Physician Application - 05/97 Page 3 of 10 Physician Name: Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic), and postgraduate edu-

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CONFIDENTIAL/PROPRIETARY California Participating ...

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