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GVN Provider recruitment

We thank you for joining the Georgia Vision Network as a provider. The Vision Network was created to meet the needs of those uninsured and underinsured around the state to provide quality eye care. 
We appreciate the completion of this form in its entirety. Please contact Jane Kuhlenbeck (jane.kuhlenbeck@emory.edu) for questions.
1.Provider Name (Required.)
2.Provider email address(Required.)
3.Specialty(Required.)
4.Subspecialty (Select all that apply)(Required.)
5.Insurance accepted- Select all that apply(Required.)
6.If you accept uninsured, do you have a flat rate for self pay?
7.If yes, what is your flat rate for self pay?
8.Do you see kids?(Required.)
9.If yes, what is the minimum age seen?
10.Practice Name(Required.)
11.Practice phone number(Required.)
12.Name of best person to contact for details (i.e practice manager, clinic manager etc)(Required.)
13.Email address for best person to contact(Required.)
14.Location(s) in which you would like to see GVN Patients (if all- please list all practice locations)(Required.)
15.Location(s) in which you see kids(Required.)
16.GVN provider type:  Select all that apply.

* If you are already registered with one of the following organizations- please select the organization- established provider

** As an independent GVN provider, patients will contact your office directly and identify themselves as a GVN patient. You agree to provide a comprehensive eye exam and needed testing. Any further follow up and management is at the discretion of you and the patient.

*** If you select Eye Care America, Prevent Blindness Georgia or Georgia Lions Lighthouse- they will be contacting you for additional information(Required.)