Keystone First Community HealthChoices Provider Responsibilities Webinar
Thank you for attending the Provider Responsibilities Webinar. Please take a moment to fill out the survey below.
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1.
Name
(Required.)
2.
Title
*
3.
Practice/organization name
(Required.)
4.
Practice/organization ZIP Code
5.
Plan assigned provider ID
*
6.
Tax identification number (TIN)
(Required.)
*
7.
Email address
(Required.)
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8.
Phone number
(Required.)
9.
Additional training needs or follow-up contact by your Account Executive
10.
Preferred method of contact
11.
Comments/suggestions
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