membership forms

If you are a new group/TIN to PPLLC, please fill out the correct form:

• -group with single provider only needs to fill out the first application (....for single provider) and the W-9 form
• -groups with multiple providers should fill out the appropriate application based on your specialty and the W-9 form, along with the "New survey for all physician applicants" for each physician in the group
• All fields must be completed in order to be considered final.

If you are a group already participating in PPLLC, please fill out an application form for each physician.  All fields must be completed for the application to be considered final.

Please fill out the attached form to terminate a physician from participation in your group. 

Please fill out the first form to make non-demographic changes:

• adding a practice address that is new to your organization, 
• adding or changing your TIN, 
• changing the scope of services provided at your practice, or 
• changing the status of a physician between PCP and specialist

Please fill out the second form for any other demographic changes to your practice or physician(s)