COREC Provider Interest Form

First Name:	(Required)
Last Name:	(Required)
Office Name:
Role:	None Billing Specialist Office Manager Office Staff Provider Other
NPI #:	(Required)
Phone Number:	() - (Required)
Fax Number:	() -
E-mail:	(Required)
Confirm E-mail:	(Required)

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Address:
Apt/Suite No.:
City:
County:
State:	ALABAMA ALASKA AK ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code:

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Provider Credentials:

None CNMW DDM DDS DMD DO DPM LD MD MSW NP OD PA PsyD PT RN   (Required)

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Comments:

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The CalOptima Regional Extension Center is a federally-designated Regional Extension Center funded by the Office of the National Coordinator, Department of Health and Human Services, Award Number: 90RC0066/01.

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