Transcription of PARTICIPATING PROVIDER AGREEMENT THIS …
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PARTICIPATING PROVIDER AGREEMENT THIS …
PARTICIPATING PROVIDER AGREEMENT August 2017 1 PARTICIPATING PROVIDER AGREEMENT THIS PARTICIPATING PROVIDER AGREEMENT (the AGREEMENT ), effective as of _____, 2019 (the Effective Date ), is made and entered into by and among Zelis Network Solutions, LLC on behalf of itself and its subsidiaries and affiliates, including any and all entities under common ownership or control, with principal offices located at Two Concourse Parkway, Suite 300, Atlanta, GA 30328, (hereinafter referred to as Network ) and Network PROVIDER as defined below: Network PROVIDER Full Legal Name: Date of Birth: Principal Business Address: Email: City, State and Zip Code: Tax ID No.: Phone No.: NPI No.: Fax No.: State License No: Exp.
Participating Provider Agreement – September 2016 1 PARTICIPATING PROVIDER AGREEMENT . THIS PARTICIPATING PROVIDER AGREEMENT (the “Agreement”)
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