Voluntary Initiative Program (VIP) Enrollment Form

1. CONTACT INFORMATION

Thank you for your participation in MSD's Voluntary Initiative Program (VIP) to join the network of Physicians, Allied Health Practitioners and Ancillary Service Providers across the state servicing patients enrolled in the state's Health Care Connection (HCC) program.

Please answer this questionnaire completely. You may contact us to make changes at any time as needed by calling MSD at 302-366-1400 or email to: info@medsocdel.org

Question Title

* 1. Please choose the answer that best fits, I am a

Physician

Allied Health Practitioner

Ancillary good/services Provider

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* 2. Name of Practice/Organization

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* 3. Your full name and credentials

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* 4. Medical License Number

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* 5. Individual NPI Number (if applicable)

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* 6. Your Email Address

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* 7. Please choose the most appropriate answer

Solo practice

group practice but only I am enrolling in VIP

group practice and all providers are enrolling in VIP

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* 8. Medical Specialty or Types of goods/services being offered

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* 9. Practice Status

Private practice

Employed (hospital)

Not Applicable

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* 10. Group NPI Number (if applicable)

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* 11. Please provide the full name, credentials, specialty, individual NPI number and email contact for any additional physicians or providers who are also enrolling as part of your practice to the VIP network.

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* 12. Primary Practice Location Address/Phone (Skip to Q23 if a business offering goods/services)

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 13. Primary Practice Location Fax number

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* 14. Do you see patients at additional locations?

Yes

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* 15. Please list the addresses and phone & fax numbers for all additional locations where you would see HCC patients.

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* 16. Mailing Address

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number

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* 17. Who should we contact for VIP related inquiries (billing, scheduling, etc)

Name and Title

Email Address

Phone Number

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* 18. Does your practice have any bilingual staff? If so, what language(s)?

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* 19. Are you a current member of the Medical Society of Delaware (MSD)?

Yes

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* 20. If you are not currently a MSD member, are you interested in membership?

Yes

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* 21. Are you a State Loan Program (SLRP) or Health Care Provider Loan Repayment Program (HCPLRP) recipient?

Yes

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* 22. Do you have a J-1 visa sponsorship?
*After answering, PLEASE PROCEED TO Q25**

Yes

Voluntary Initiative Program (VIP) Enrollment Form

1. CONTACT INFORMATION

Question Title

* 1. Please choose the answer that best fits, I am a

Question Title

* 2. Name of Practice/Organization

Question Title

* 3. Your full name and credentials

Question Title

* 4. Medical License Number

Question Title

* 5. Individual NPI Number (if applicable)

Question Title

* 6. Your Email Address

Question Title

* 7. Please choose the most appropriate answer

Question Title

* 8. Medical Specialty or Types of goods/services being offered

Question Title

* 9. Practice Status

Question Title

* 10. Group NPI Number (if applicable)

Question Title

* 11. Please provide the full name, credentials, specialty, individual NPI number and email contact for any additional physicians or providers who are also enrolling as part of your practice to the VIP network.

Question Title

* 12. Primary Practice Location Address/Phone (Skip to Q23 if a business offering goods/services)

Question Title

* 13. Primary Practice Location Fax number

Question Title

* 14. Do you see patients at additional locations?

Question Title

* 15. Please list the addresses and phone & fax numbers for all additional locations where you would see HCC patients.

Question Title

* 16. Mailing Address

Question Title

* 17. Who should we contact for VIP related inquiries (billing, scheduling, etc)

Question Title

* 18. Does your practice have any bilingual staff? If so, what language(s)?

Question Title

* 19. Are you a current member of the Medical Society of Delaware (MSD)?

Question Title

* 20. If you are not currently a MSD member, are you interested in membership?

Question Title

* 21. Are you a State Loan Program (SLRP) or Health Care Provider Loan Repayment Program (HCPLRP) recipient?

Question Title

* 22. Do you have a J-1 visa sponsorship? ***After answering, PLEASE PROCEED TO Q25

* 22. Do you have a J-1 visa sponsorship?
*After answering, PLEASE PROCEED TO Q25**