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IIC Provider Application
Please mail completed application packets (original signatures) to the Children’s System of Care as instructed in the materials below.
Please include a copy of your resume, credentials and certificates obtained that are relevant to any listed specializations.
Click HERE to view guidelines for filling out the IIC Provider application.
- IIC Application Cover Letter
- Notice to Enrollee(s)
- Request for National Provider Identifier (NPI)
- Signature Authorization Form
- Provider Application-FD-20
- Provider Agreement-FD-62
- Disclosure of Ownership and Control Interest Statement
- W-9 Tax Form
- Affirmative Action Survey (Optional)
- Authorization of Automatic Payments & Deposits
- Agreement of Understanding
- Provider Profile Information Form