PC- Evaluation Form

Applicant Name

1.

Name the parties between which Physician Provider Participation agreement is made.

2.

What is the Claim submission Deadline?

3.

What is the time limit given to breaching party to cure a breach?

4.

Name any 1 cause for immediate Termination by participating provider?

5.

What is the process of termination without cause?

6.

What is the effective date and termination date of the agreement?

7.

What is your greatest strength?

8.

What do you consider to be your biggest weakness?