New Physician Please enable JavaScript in your browser to complete this form.Your Name *Name of person completing form Your Email *Date *Date form completed Physician Data Name *FirstLastBusiness Name *Legacy Care Email Address *Cell Phone Number *Assigned FacilityAnticipated Start Date *Provider NPI # *Found on credentialing packetPayment MethodRVUMSOPayment RatePayment Rate Legacy Care Med MalYesNoMedical Director YesNoAnticipated Start DateAssigned Facility Invoiced AmountMonthly/Hourly rate billed by Legacy CareTimesheet Required for InvoiceYesNoInvoice Recipient NameFirstLastInvoice Recipient EmailEmail address to receive invoice for monthly stipend from Legacy CareStipend Amount Monthly/Hourly rate provider receives Collaborating APP NameFacility NameStart DateCollaboration StipendNameFacility NameStart Date Collaboration StipendNameFacility NameStart Date Collaboration Stipend NameFacility NameStart Date Collaboration StipendName Facility NameStart Date Collaboration Stipend NameFacility Name Start Date Collaboration Stipend Optional NotesSubmit
