Global Preferred Provider Participation Form
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1
2Please send completed form to:
CMN Inc.
Attn: Provider Relations
150 Commerce Valley Drive West, 9th Floor
Thornhill, Ontario, Canada L3T 7Z3
Tel: +1-905-669-4333 x1247
Fax: +1-905-669-2318
E-mail:
Global Preferred Provider Participation Form (non-US)
CMN Inc. is very interested in learning more about your healthcare services and would like to include your facility as a Global Preferred Provider.
Please complete the form and return to Provider Relations via e-mail to or fax +1-905-669-2318.
A. TYPE OF FACILITY
Hospital
Medical Centre/Clinic
Physician/Specialist
Dentist
Lab/Diagnostic Centre
Pharmacy
Medical Equipment
B. FACILITY INFORMATION
Facility Name
Physical Address
City
Region/Province/State
Postal/Zip Code
Country
Telephone
Fax
Website Address
(include city and country codes)
(include city and country codes)
Languages - Please check all that apply
English speaking staff and doctors
List other languages
Translators
C. DEPARTMENTAL CONTACT INFORMATION
International Department
Telephone
(include area code)
E-mail Address
(
)
Scheduling and Admissions
Telephone
(include area code)
E-mail Address
(
)
Contracting
Telephone
(include area code)
E-mail Address
(
)
Billing/Patient Accounts (Department Manager)
Telephone
(include area code)
E-mail Address
(
)
D. JCI ACCREDITATION
Is your hospital JCI Accredited?
Yes
No
If Yes, please specify details of your most recent accreditation
Date of Last Accreditation (MM/DD/YYYY)
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Global-Preferred-Provider-Participation-Form-Non-US-10.pg1 01/2011
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Parent category: Medical