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Physician/Provider Name:* Practice Name: Hospital Affiliation: Specialty*

Contact Person: Street Address: City:* State* Zip Code:* County:* Email Address:* Phone Number:*

Do you currently accept Medicaid?: * Yes No

Do you currently accept Medicare?: * Yes No

Are you Board Certified?: * Yes No

Are you currently participating with Gateway?: * Yes No

Which Line(s)-of-Business are you interested in applying for?: * Medicaid Medicare Healthy PA