Whether you are a new group wishing to join, or an existing group wishing to add a new physician or make demographic or practice changes, you've come to the right place. Click below for more details about the process, or click on one of the 4 boxes below if you know what you want to do!
Enrollment Process - Overall Summary (docx)
DownloadApplications 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
Use these forms to change demographic or non-demographic information for your group or a physician(s) in your group
If you are a new group/TIN to PPLLC, please fill out the correct form:
Application Request for PPLLC Participation for single provider 9-9-21 (pdf)
DownloadApplication Request for PPLLC Participation_9-9-21 (pdf)
DownloadApplication Request for PPLLC Participation9-9.2021 - OBGYN (pdf)
DownloadApplication Request for PPLLC Participation_9-9-21 - Dermatology (pdf)
DownloadApplication Request for PPLLC Participation_9-9-21 - Podiatry (pdf)
DownloadNew survey for all physician applicants 9-7-21 (pdf)
Downloadblank w9 form (pdf)
DownloadIf 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.
New survey for all physician applicants 9-7-21 (pdf)
DownloadPlease fill out the attached form to terminate a physician from participation in your group.
PPLLC Provider Termination Form - final (pdf)
DownloadPlease fill out the first form to make non-demographic changes:
Please fill out the second form for any other demographic changes to your practice or physician(s)
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