Participating Provider Request

Facility Information

Legal Entity Name: *

Tax ID: *

Same as Legal Entity Name?

Name of d/b/a (if applicable):

Website:

Phone Number: *

Fax Number:

Mailing Address: *

City: *

State: *

Zip Code: *

Primary Contact Information

Primary Contact Full Name: *

Phone: *

Email: *

General Information

Total Number of Locations:

Total Number of Practitioners:

Medicare Certified Facility: *

Yes

No

Total Number of Medicare Certified Practitioners:

Medicaid Certified Facility: *

Yes

No

Total Number of Medicaid Certified Practitioners:

Facility Type: *

Hospital Clinic Nursing Home Surgery Center Behavioral Health Inpatient/Residential ACA Essential Care Provider Other

Other Facility Type

Practice Specialties

Specialty Type: *

PCP Specialty Behavioral Health Optometry OT/PT/Speech Autism Dialysis Other

Other Specialty

Describe the services you provide: *

Primary hours of operation:

After hours/emergency call process:

Facility Accessibility

Is the exterior of your facility location/building accessible for people with physical disabilities?: *

Yes

No

Is the interior of your facility/office accessible for people with physical disabilities?: *

Yes

No

Are your exam rooms accessible for people with physical disabilities?: *

Yes

No

Does your office have equipment to accommodate for people with physical disabilities?: *

Yes

No

Does your office have restrooms to accommodate for people with physical disabilities?: *

Yes

No

Thank you for your interest in becoming a Quartz participating provider. Your application will be evaluated for participation in all Quartz affiliated networks.

Facility Information

Primary Contact Information

General Information

Practice Specialties

Facility Accessibility

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