Provider Network Contract Annual Registration: Form 440 ...
|[pic] |Department of Consumer and Business Services | |
| |Oregon Insurance Division — 4 | |
| |P.O. Box 14480, Salem, Oregon 97309-0405 | |
| |350 Winter St. NE, Salem, Oregon 97301-3883 | |
| |Phone: 503-947-7982 Fax: 503-947-7862 | |
| |Email: orinsreg.ins@state.or.us | |
| |insurance. | |
| |
| |
|Name of entity |
| | | | | |
|Domicile |Date established |FEIN number |
| |
|Mailing address line 1 |
| |
|Address line 2 |
| | | | | |
|City |State |ZIP |
| | | | | |
|Phone number |Fax number |Email address |
| |
|Physical address line 1 |
| |
|Address line 2 |
| | | | | |
|City |State |ZIP |
| | | | | |
|Phone number |Fax number |Email address |
| |
|Administrative contact person |
| |
|Mailing address line 1 |
| |
|Address line 2 |
| | | | | |
|City |State |ZIP |
| | | | | |
|Phone number |Fax number |Email address |
| | | |
|Signature of owner / principal | |Date |
| Visa | MasterCard | Discover |Phone: | | |Make check or money order payable to: |
| | | | | | |Department of Consumer and Business Services. |
| | | | | | | |
| | | | | | |Mail registration with payment to: |
| | | | | | |DCBS — Fiscal Services |
| | | | | | |P.O. Box 14610 |
| | | | | | |Salem, OR 97309-0445 |
| | | | | |
|Credit card number | |Expiration date | | |
| | | | | |
|Name of cardholder as shown on credit card | | | | |
| | |$ | | |
|Cardholder signature | |Amount | | |
|Secure fax for credit card payments: | |Fiscal use only: 92010/1010 |
|503-947-2333 | |Fee: $150.00 |
|If paying by credit card, applicant must sign | | |
|credit-card information box. | | |
|[pic] | | |
|440-1084 (11/13/COM) | | |
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Provider Network Contract Registration Form
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