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Carroll PHO Membership Application

Application to the PHO is done electronically. Please complete the form below, or if you have more providers than the form allows for, call 410-871-7249 to request a spreadsheet.

Notes:
  • Practice office managers/administrators and lead physician(s) will be the primary points of contact for the PHO.
  • List other physicians in the practice and mid-level providers after the lead physician(s).
  • Specialty does not need to be repeated for all providers if same as first.
  

Practice Information

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Practice Name
*
Tax Identification Number
*
Administrator or Office Manager
*
E-mail
*
Phone Number

Physicians

*
Lead Physician 1
*
Specialty
*
E-mail
*
Best Phone Number

cell or back office

Lead Physician 2
Specialty
E-mail
Best Phone Number

cell or back office

Lead Physician 3
Specialty
E-mail
Best Phone Number

cell or back office

Other physicians joining the PHO from this practice

Physician 1
Physician 1 Specialty
Physician 1 E-mail
Physician 2
Physician 2 Specialty
Physician 2 E-mail
Physician 3
Physician 3 Specialty
Physician 3 E-mail

Mid-Levels

PAs or NPs associated with this practice

PA/NP 1
PA/NP 1 E-mail
PA/NP 2
PA/NP 2 E-mail
PA/NP 3
PA/NP 3 E-mail

EMR Information

Name of EMR System

If applicable.

Best contact for EMR data extraction

EMR Contact
EMR Contact E-mail
EMR Contact Phone Number