FAMILY PACT (FAMILY PLANNING, ACCESS, CARE AND TREATMENT) PROGRAM PRACTITIONER PARTICIPATION AGREEMENTPractitioner Participation Agreement • August 25th, 2022
Legal Name of Practitioner Individual National Provider Identifier (NPI) Site Certifier Yes No Service Site E-mail Address Service Site Telephone Number Service Site FAX Number
FAMILY PACT (PLANNING, ACCESS, CARE, AND TREATMENT) PROGRAM PRACTITIONER PARTICIPATION AGREEMENTPractitioner Participation Agreement • December 29th, 2016
BLUE CROSS AND BLUE SHIELD OF MICHIGAN PRACTITIONER TRADITIONAL PARTICIPATION AGREEMENTPractitioner Participation Agreement • May 19th, 2016 • Michigan
THIS AGREEMENT is made by and between Blue Cross Blue Shield of Michigan, a Michigan nonprofit healthcare corporation, (“BCBSM”) and the undersigned Practitioner who is fully licensed or legally authorized to practice in the state of Michigan ("PRACTITIONER").
FAMILY PACT (FAMILY PLANNING, ACCESS, CARE AND TREATMENT) PROGRAM PRACTITIONER PARTICIPATION AGREEMENTPractitioner Participation Agreement • August 15th, 2022
Legal Name of Practitioner Individual National Provider Identifier (NPI) Site Certifier Yes No Service Site E-mail Address Service Site Telephone Number Service Site FAX Number
