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| Thank you for your interest in joining Alliance Medical Network, a division of Alliance Health Network, Inc. Please follow the instructions below carefully. In order to process your application and agreement, all materials must be complete and all attachments must be present. Incomplete applications will not be processed. |
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Alliance Medical Management and Alliance Health Network are divisions of Alliance Health Network, Inc. (Alliance) has established the following criteria with respect to physician membership with Alliance. Each physician applying for membership must satisfy Alliance, as a condition precedent, and as a condition for continued participation, that the physician meets the criteria set forth below.
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- The physician must be a member is good standing of the Medical Staff at an approved hospital with provisional, courtesy, or active privileges. If the physician does not have privileges at an approved hospital, and will be referring his/her patients to another physician for admission to the hospital, the patient must be turned over to a participating physician, and there must be a written verification from the admitting physician stating he/she will be admitting for the physician.
- The physician must be duly licensed in the State of California.
- The physician must be Board Certified or Board Eligible in the specialty in which they are applying; or have satisfactory post garduate education and training and/or experience in the specialty in which they are applying.
- The physician must possess professional liability insurance coverage in such minimum amounts as are from time to time designated by Alliance. The initial minimum coverage limitations established by Alliance are $250,000 for each occurrence and $750,000 aggregate annual coverage. Satisfactory evidence of the required coverage must be provided to Alliance. The physician must agree to give Alliance a minimum of ten days advance notice of any cancellation in coverage or any reduction in coverage below the established minimum requirements.
- The physician must be willing to give Alliance all information reasonably requested concerning any medical malpractice actions instituted against, settlements made by, or judgments entered against the physician.
- The physician must agree to participate in and comply with the Utilization Review program, Quality Assurance program, and billings, payments, and claims procedures and comply with other protocols, rules, procedures and regulations established from time to time by Alliance in its reasonable discretion.
- The physician must agree to provide medical services to Alliance participants on the same basis as such services are provided to private patients.
- The physician must agree to enter into a Membership Agreement with Alliance, containing such terms and conditions as Alliance may from time to time determine are reasonable.
- The physician must provide Alliance with any information pertaining to health status, sanctions, restrictions or suspensions on all licenses and hospital privileges, or felong convictions.
- The physicians shall provide and agree to the fee and administrative procedures of the Alliance Health Network.
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| Our Membership Application Agreement is in a downloadable PDF format. PDFs require Adobe Acrobat Reader to be viewed. If you do not have Acrobat Reader, it may be downloaded, free of charge, from the Adobe website. |
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- Download the Alliance Membership Agreement Application, print, complete and sign the application, including the applicant's initials and signature, printed name, and the date the application was signed where required.
- Complete in full, signature page on both agreements.
- All questions must be answered completed.
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Completed and signed Application (Alliance must receive the application within thirty (30 ) days of the signature date.- Copy of current malpractice insurance certificate.
- Copy of current DEA certificate (if applicable).
- Copy of current DPS certificate (if applicable).
- Copy of Board Certification Certificate(s) (if applicable).
- Copy of ECFMG Certificate (if applicable).
- Copy of current license.
- Copy of W-9.
- Copy of Curriculum Vitae.
- Detailed explanation for any employment gaps.
Please return all materials in one envelope.
Upon receipt of your completed application, Alliance will begin
the membership process. You will be notified once the process
has been completed. Alliance will add you to the network upon
approval of the application process and become effective within
thirty (30) days after approval is complete.
Please contact our member coordinator at (949) 756-1628 if you
have questions regarding your application or email: george@alliancehealthnetworkinc.com |
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Please notify Alliance of updates to your practice information. Keeping Alliance updated will assist our ability to keep you posted on health information and related news. Please provide any updates regarding the items below. CHANGES CANNOT BE MADE RETROACTIVE:
- Tax Identification Number (TIN) changes (New W-9)
- Tax Identification Name Changes (New W-9)
- Address Changes
- Telephone Number Changes
Send updated information to the following address or fax number:
Alliance Health Network, Inc.
Member Coordinator
4220 Von Karman, Suite 120
Newport Beach, CA 92660
Fax: 949-955-9446
Please contact our Member Coordinator at 949-756-1628, if you have questions.
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