New Specialty Verification Document
Provider Category Attestation
Provider Last Name: Provider First Name:
Degree: Category:
Specialty: Primary Practice: Specialty: Secondary Practice:
I am a Specialist Provider. I attest that I understand that I am not practicing as a Primary Care Provider even if I am trained or board certified in a Primary Care Provider designated specialty.
 
I am a Primary Care Provider. I attest that I may be assigned a patient panel and may be chosen by plan members as their Primary Care Provider. I attest that I understand that I am not practicing as a Specialist Provider even if I am trained or board certified in a Specialist designated specialty.
 
I am a Dual Practice Provider. I attest that I am a Primary Care Provider and as such, I may have a patient panel assigned to me or I may be chosen by a plan member as their Primary Care Provider. I further attest that I am also a Specialist Provider and may have referrals made to me in my chosen specialty.
 
I am an Allied Health Provider. I attest that I am neither, a Primary Care or Specialist Physician Provider.
 
Check if you agree with all the answers in this form  
       
Provider NPI: Your Full Name:
Today's Date:  
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