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DIRECTORY LISTING: Please complete the following as you would like it to appear in The Health Connection Directory. Your Listing Is Free!

Provider Preliminary Registration Form

Practice Name:
Provider First Name:
Provider Last Name:
Degrees Held:	(i.e., MD, LAc., LMT, PhD)
Street Address:

City:
State:	Zip Code:
County:
Phone:
Fax:
Email Address:
Website:
Category Listing(s):
	1)
	2)
	3)
	4)

It is hereby agreed that Provider will offer Health Connection subscribers a minimum discount of 20% or 25% or % Other (20% minimum)

Some providers have asked us to have the option to provide a free initial consultation in order to encourage the use of their services. Do you wish to provide a free initial consultation? Yes No

Participation in the Network will be on a contingency basis pending the return of the provider agreement application and the credentialing data request form. These forms will be mailed to you upon receipt of this Preliminary Registration.

For additional information or questions, please call one of our Provider Specialists at 1-800-634-2968.

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