Opt-in Provider Letter SCP

Dear Participating Provider:

Apricus Health Network (the “Group”) has reached an agreement with Devoted Health Plan of Arizona (“Devoted”) to employ or contract with medical practitioners and other health care providers to provide health care covered services through a CMS-approved benefit plan for which a Devoted member (“covered person”) is entitled under the member’s benefit plan.

Special Care Physicians (SCPs) shall be paid at 100% of Fee-For-Service (FFS) Medicare rates

To opt-in the Group’s network assignment or appointment, please sign and date below and return to Apricus Health Network, within 30 calendar days from the date of this notice. Send to the attention of: James J. Walsh, Jr., Chief Operating Officer (COO), via email: jwalsh@apricushealth.com or mail to: 16435 N Scottsdale, suite 400, Scottsdale, Arizona, 85254.

Thank you. Should you have any questions or need further clarification, please contact me at (602) 675-9005.

Sincerely,

James J Walsh, Jr., COO
Apricus Health Network
jwalsh@apricushealth.com
16435 N Scottsdale Rd, suite 400
Scottsdale, Arizona 85254
To Opt-In from Network Appointment/Assignment under Devoted Health Plan:
Name of Provider *

First Name Last Name
Professional Title
Signature of Provider
Signature

Clear
Group Name
Address:
Street Name & Number:
City, State & Zip Code:
TIN #:
Group NPI #
Fax #
Please enter a valid phone number.
Email
example@example.com
Signature Date
Date

Month Day Year
Date
Should be Empty: