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Demographics

Full Name*

Degree*

Years in Pratice*

Email Address*

Primary Office Address

Street*

Suite

City*

State*

Zip*

Hours

Phone(s)

Secondary Office Address

Street

Suite

City

State

Zip

Hours

Phone(s)

Practice Information

I Practice as a*
Primary Care PhysicianSpecialist

I am Board Certified in

A.

B.

C.

I want to practice under the following specialties

A.

B.

C.

List any special skills you have in your practice

Languages spoken by you

Languages spoken by your Staff

I own my own practice?
YesNo

I have hospital privileges at
EI Camino Hospital Mt. ViewGood SamaritanO'ConnorRegional Med CenterEI Camino Hospital Los GatosSt. LouiseSanta Clara Valley MedStanford/LPOther

Hospital privileges Other Option

I share office space with other provider(s) who are not a group?
YesNo

Please list other provider(s)

I belong to a Group?
YesNo

The Name of Group is

What is your relationship with the group?
Employer/employee relationshipPartner/share ownershipShare expenses of the practiceOther

Relationship with the group: Other Option

I have Ambulatory Surgery center privileges at:
Advanced Surgery CenterBascom Surgery CenterEI Camino Surgery CenterMontpelier Surgery CenterForest Surgery CenterOther

Ambulatory Surgery center privileges: Other Option

What patient population are you willing to see(*PMGSJ requires all specialists to accept the following types of plans)?
HMO CommercialHMO Medi-CalMedicare Advantage

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