Application

How to join:

. . .

Step 1: Complete the application below and Submit
Step 2: We will respond via email with our Membership Agreement and a Membership Invoice
Step 3: You sign and return the agreement via email (admin@ipnetworkflorida.net) or fax (407-475-9203)
Step 4: You mail the membership fee to our Corporate Address listed on the invoice

Membership fees are only $100 per Physician

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New Member Application

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Practice Information

* Indicates required field

* Please use NA if a field does not apply to your office.

Your Practice Website *

The Name of the Practice *

Name of Owner or COO of the Practice *

What is your Specialty? *

Managers Name *

First

Last

Managers Email *

Is the email above correct? *

Yes

Tax ID *

Group NPI *

Group BlueCross Blue Shield ID # *

Number of Offices *

In what year did you start your first Practice? *

Primary Office Address *

Line 1

Line 2

City

State

Zip Code

Country

County of the Primary Office *

Office Phone Number *

Fax Number *

Electronic Medical Records *

We have one Do not have one yet

What EMR do you use? *

Name of your malpractice Insurance: *

Group Medicaid # *

Comment *

1st Hospital Affiliation *

2nd Hospital Affiliation *

3rd Hospital Affiliation *

. . .

Billing Information
Please give us information on the office that bills your patients

. . .

Physicians information

We only need demographic information for your full-time and part-time physicians,
not for any mid-level or ancillary providers.

1-Physicians Name or Senior Partner *

First

Last

Choose One *

MD DO OD DC

1-Physicians Date of Birth *

1-Physicians email *

1-Physician's mobile phone number *

1-Physicians Medical License# *

1-Physicians CAQH# *

1-Physicians DEA# *

1-Physicians NPI# *

1- Physicians Medicaid# *

1-Physicians BlueCross Blue Shield id# *

. . .

2-Physicians Name *

First

Last

Choose One *

MD DO OD DC

2-Physicians Date of Birth *

2-Physicians email *

2-Physician's mobile phone number *

2-Physicians Medical License# *

2-Physicians CAQH# *

2-Physicians DEA# *

2-Physicians NPI# *

2- Physicians Medicaid# *

2-Physicians BlueCross Blue Shield id# *

. . .

3-Physicians Name *

First

Last

Choose One *

MD DO OD DC

3-Physicians Date of Birth *

3-Physicians email *

3-Physician's mobile phone number *

3-Physicians Medical License# *

3-Physicians CAQH# *

3-Physicians DEA# *

3-Physicians NPI# *

3- Physicians Medicaid# *

3-Physicians BlueCross Blue Shield id# *

. . .

4-Physicians Name *

First

Last

Choose One *

MD DO OD DC

4-Physicians Date of Birth *

4-Physicians email *

4-Physician's mobile phone number *

4-Physicians Medical License# *

4-Physicians CAQH# *

4-Physicians DEA# *

4-Physicians NPI# *

4- Physicians Medicaid# *

4-Physicians BlueCross Blue Shield id# *

. . .

5-Physicians Name *

First

Last

Choose One *

MD DO OD DC

5-Physicians Date of Birth *

5-Physicians email *

5-Physician's mobile phone number *

5-Physicians Medical License# *

5-Physicians CAQH# *

5-Physicians DEA# *

5-Physicians NPI# *

5- Physicians Medicaid# *

5-Physicians BlueCross Blue Shield id# *

. . .

How many Mid levels Providers: *

How many providers work 3 days or less: *

Office hours

Office Week Days Open/Close Hours *

Weekend Hours Open/Close *

Please specify "others": *

Is your LAB: *

CLIA Waived CLIA Moderate CLIA Complexity

Other Labs please specify: *

Ancillary Services: Specify: *

Submit

Contact Information
1101 N. Lake Destiny Road
Suite 300
Maitland Florida 32751

Phone: 407-475-9213
Fax: 407-475-9203

Your 2018 IP Network Board of Directors are:

Mark Chaet, MD, President
Jason Pirozzolo, DO, Vice President
Hank Levine, MD
Lara Hitchcock, MD
George White, MD, Past President

Larry Jones, Executive Director
Kathy Monnett, Corporate Exec Asst
April Peterson, Director of
Network Management
Kaitlyn Carrick, Physician Liaison
Maxine Jones, RN, Nurse Case Manager

Your Advisory Board Members for 2017 are:

Victor Roberts, MD
Doug Sprung, MD
Jason Sniffen, DO
Julio Paez, MD
Pamela Snook, MD
Paul Shuler, MD
Steve White, MD
David McDonald, MD

How to join:

New Member Application

Practice Information

Billing InformationPlease give us information on the office that bills your patients

Physicians information

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Office hours

Billing Information
Please give us information on the office that bills your patients