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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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