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Physician / practitioner information

First name:*

Last name:*

Practice name:

Office address:

City:

State:

Zip code:

Phone (including U.S. area code):

Please enter a 10 digit phone number with no country code, special characters or spaces

Fax (including U.S. area code):

Please enter a 10 digit phone number with no country code, special characters or spaces

Email:*

Electronic Health Records (EHR) system:

Billing information

Same as contact information

Billing address:

City:

State:

Zip code:

Phone (including U.S. area code):

Fax (including U.S. area code):

Email:

Additional information

Office hours:

Electronic (EDI) Claims Clearinghouse:

ABMS certification status:

Board certified

Non board certified

Board eligible

Date of scheduled exam (MM/DD/YYYY):

Medicare Provider Transaction Access Number (PTAN):

National Provider Identification Number (NPI):

Individual:

Group:

As a provider with Monarch HealthCare, I would provide service to HMO and:

CalOptima

Medi-Cal

(Provider MUST be enrolled with State Medi-Cal Program)

Have you ever been a Monarch HealthCare Provider in the past?

Yes

My primary specialty is:

My secondary specialty is:

The language(s) I speak:

The language(s) my office speak:

My outpatient surgery center affiliation(s) is/are:

I have ownership in the following outpatient surgery center(s):

I have hospital privileges at: