Transcription of CONFIDENTIAL/PROPRIETARY California Participating ...
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California Participating physician Application - 05/97 Page 1 of 10 physician Name: CONFIDENTIAL/PROPRIETARY California Participating physician Application This application is submitted to:MDI , herein, this Healthcare Organization1 I. INSTRUCTIONS: This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. Current copies of the following documents must be submitted with this application: State Medical License(s) Face Sheet of Professional Liability Policy or Certification DEA Certificate Curriculum Vitae Board Certificatio
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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