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Provider Applications, Contracts, etc.

New solo practice or group?

Complete, sign and return:

1.    1 Provider Service Agreement per tax ID #

2.    1 W-9 Form per tax id #

3.    1 credentialing app, per physician

4.    1 attestation release agreement per application

5.    All requested attachments

Already contracted and adding physicians? Complete, sign, and return everything EXCEPT the Provider Service Agreement.

DELPHI CARD® & it's members thank you!

The following forms are available:

· The following forms are available:

· Illinois Credentialing Application

· Attestation Release Agreement

· Provider Service Agreement

· W-9 Request for Tax Identification

Please mail all materials to:

DELPHI CARD®
Provider Relations
P.O. Box 29
Fox River Grove, IL 60021-0029