Rovider Registration Form - Alabama Department Of Public Health
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3INTERIM FEDERAL HEALTH PROGRAM (IFHP)
PROVIDER REGISTRATION FORM
PART A: PROVIDER INFORMATION (Please print clearly)
Provider Name:
Business Name:
Business Address:
City:
Province/Territory:
Postal Code:
Telephone Number: (
)
Fax Number: (
)
E-mail Address:
Language of Choice:
English
French
Contact Person (if different from above):
Cheque Payment Name:
Mail/Cheque Address (if different from above):
Address:
City:
Province/Territory:
Postal Code:
Additional Location
Business Address:
City:
Province/Territory:
Postal Code:
Telephone Number: (
)
Fax Number: (
)
E-mail Address:
PART B: PROVIDER TYPE/SPECIALTY
Provider Type (ex. Physician, Dentist, Physiotherapist)/Specialty:
Designated Medical Practitioner Number, if applicable:
Medavie Blue Cross Provider Number (if applicable):
Association/Regulatory Body Name:
License/Registration Number:
Province/Territory of Registration:
COMMENTS/ADDITIONAL INFORMATION
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