membership forms

Applications to join PPLLC depending on specialty, and forms for your physicians to apply if you are not a single provider TIN

If you are already participating in PPLLC, use this form to apply to add physicians to your group

Use this form to terminate a physician from PPLLC who is no longer a part of your group

Forms for application of new group/tin to ppllc

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
-groups with multiple providers should fill out the appropriate application, along with the "New survey for all physician applicants" for each physician in the group

Application Request for PPLLC Participation for single provider 4-9-21 (pdf)

Application Request for PPLLC Participation_4-13-21 (pdf)

Application Request for PPLLC Participation_4-9-21 - Dermatology (pdf)

Application Request for PPLLC Participation 4.9.2021 - OBGYN (pdf)

Application Request for PPLLC Participation_4-9-21 - Podiatry (pdf)

New survey for all physician applicants 4-13-21 (pdf)