Common Contracts

HHC Connectx Provider Enrollment and Referral Agreement‌

February 9th, 2009

• Filed
  February 9th, 2009

Last Name: First Name: Middle Initial: Degree(s): Sex: Indicate Specialty 1:Board Certified?: Yes No Certified Date: Indicate Specialty 2:Board Certified?: Yes No Certified Date: Languages: Email Address: Emergency phone #/pager #: HIV Specialist? : Yes No NY State License #: NPI #: MetroPlus Health Plan Provider? : Yes No Provider #:Medicaid Managed Care HIV SNP Medicare Managed Care Healthfirst Health Plan Provider?: Yes No Provider #:Medicaid Managed Care Medicare Managed Care