Contract Notification Form: Dr. Federal Tax ID: Three Rivers Provider Network (TRPN) America’s Choice Provider Network PPO (ACPN) PPO I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Contract I Decline Participation in this Contract Three Rivers Provider Network (TRPN) America’s Choice Provider Network Workers Compensation (ACPN) Workers Compensation I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Contract I Decline Participation in this Contract Three Rivers Provider Network (TRPN) America’s Choice Provider Network Auto Injury (ACPN) Auto Injury I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Contract I Decline Participation in this Contract FedMed PPO Med Cost Pros PPO I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Contract I Decline Participation in this Contract FedMed Workers Compensation Med Cost Pros Workers Compensation I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Patient I Decline Participation in this Contract Contract Med Cost Pros Auto Injury FedMed Auto Injury I Accept Participation in this Contract I Accept Participation in this Contract I Decline Participation in this Contract I Decline Participation in this Contract You may opt in or out of a contract at any time throughout the year by sending in written notification of the specific contract name and product. Please note if one or more contracts do not have a selection you will automatically be opted out of that patient contract. Signature: Date:
Contract Notification Form: Dr. Federal Tax ID: Three Rivers Provider Network (TRPN) PPO I Accept Participation in this Contract I Decline Participation in this Contract Three Rivers Provider Network (TRPN) Workers Compensation I Accept Participation in this Contract I Decline Participation in this Contract Three Rivers Provider Network (TRPN) Auto Injury I Accept Participation in this Contract I Decline Participation in this Contract FedMed PPO I Accept Participation in this Contract I Decline Participation in this Contract FedMed Workers Compensation I Accept Participation in this Contract I Decline Participation in this Patient Contract FedMed Auto Injury I Accept Participation in this Contract I Decline Participation in this Contract America’s Choice Provider Network (ACPN) PPO I Accept Participation in this Contract I Decline Participation in this Contract America’s Choice Provider Network (ACPN) Workers Compensation I Accept Participation in this Contract I Decline Participation in this Contract America’s Choice Provider Network (ACPN) Auto Injury I Accept Participation in this Contract I Decline Participation in this Contract Med Cost Pros PPO I Accept Participation in this Contract I Decline Participation in this Contract Med Cost Pros Workers Compensation I Accept Participation in this Contract I Decline Participation in this Contract Med Cost Pros Auto Injury I Accept Participation in this Contract I Decline Participation in this Contract You may opt in or out of a contract at any time throughout the year by sending in written notification of the specific contract name and product. Please note if one or more contracts do not have a selection you will automatically be opted out of that patient contract. Signature: Date:
blank_credentialing_form_with_agreement_and_contracts.docx