:: Doctors Care :: Physician Sign-Up

Physician Sign-Up

Physician's Name:
Practice Name:
Specialty:
E-mail:
Address:
City:
State:	Colorado
Zip:
Phone:
Fax:
Office Manager's Name:
	Spanish Translation Available
I have privileges at the following hospitals:
	Swedish Medical Center
	Porter Adventist Hospital
	Littleton Adventist Hospital
	Sky Ridge Medical Center
	Parker Adventist Hospital
Other Physicians or Mid-Levels at my practice willing to participate:

Number of Doctors Care patients I am willing to manage at a time (or number of patients the practice will manage at a time):

	I would like an inservice at my office to learn more about Doctors Care
Submission of this form agrees to participation with Doctors Care. I understand I may change participation level at any time by contacting the Program Director.
Person filling out this form:	(your name)
Initials:	(this serves as your electronic signature)

Doctors Care • 191 East Orchard Road, #102NE • Littleton, CO 80121 • 303.730.1313 • Fax: 303.730.2090