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    • Home
    • Menu
      • About Us
      • Updates
      • Billing and Coding
      • Joining PPLLC - Forms
      • News
      • Contact Us
    • Provider Directory

(617) 632-9728

  • Home
  • Menu
    • About Us
    • Updates
    • Billing and Coding
    • Joining PPLLC - Forms
    • News
    • Contact Us
  • Provider Directory

joining ppllc

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)

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membership forms

New to PPLLC

Adding a physician to a group already participating

Adding a physician to a group already participating

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

Learn more

Adding a physician to a group already participating

Adding a physician to a group already participating

Adding a physician to a group already participating

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


Learn more

Form to terminate a physician from your group

Change information for your group or physician(s)

Change information for your group or physician(s)

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


Learn more

Change information for your group or physician(s)

Change information for your group or physician(s)

Change information for your group or physician(s)

Use these forms to change demographic or non-demographic information for your group or a physician(s) in your group

Learn more

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 (....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.

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

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Application Request for PPLLC Participation_9-9-21 (pdf)

Download

Application Request for PPLLC Participation9-9.2021 - OBGYN (pdf)

Download

Application Request for PPLLC Participation_9-9-21 - Dermatology (pdf)

Download

Application Request for PPLLC Participation_9-9-21 - Podiatry (pdf)

Download

New survey for all physician applicants 9-7-21 (pdf)

Download

blank w9 form (pdf)

Download

Adding a physician to a group already participating

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.

New survey for all physician applicants 9-7-21 (pdf)

Download

form to terminate a physican from your group

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

PPLLC Provider Termination Form - final (pdf)

Download

form to make changes for your group or physician(s)

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)

PPLLC non-demographic change form 1-27-22 (pdf)

Download

BILHPN Demographic Change Form 1-27-22 (docx)

Download

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