Network Provider Application

Keystone Cares Foundation

Network Provider Application
Please list your current contact information:
Email*
example@example.com
Name of your clinic/center/practice*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Website Address (if applicable)
Name of Lead Practitioner (please include relevant titles/credentials) *

First NameLast Name
Does your organization accept health insurance?*

YesNo
Does your organization offer virtual/telehealth services?*

YesNo
Please list procedures and/or therapies that your organization offers to clients and/or patients.*
Does your organization specialize in the treatment of certain conditions? If yes, please specify in the space below. If no, type N/A*
Please upload a valid diploma or certificate from an accredited college.

Cancelof
Please upload a copy of your stated medical license number, if applicable.

Cancelof
If you do not have a diploma or certificate, please provide a description of the therapy/modality that you or your practice employs.
By checking this box, you are confirming the following: 1) that you, the applicant, has not been the subject of any material allegation or finds of non-compliance or violation of any federal or state regulations relating to the care of service that are subject of the application; 2) that you, the applicant, has not been and is not the subject of any material complaint or past, pending, or threatened litigation relating to the care or services that are the subject of this application.*

Yes
If the applicant has anything to disclose, please submit an explanation and supporting documentation, either by uploading a document or typing in the area provided below.

Cancelof
Please enter your explanation here.
I, The Applicant, hereby certify that I have reviewed this application and, to the best if my knowledge, all of the information and materials provided in this application are true and accurate. I agree to promptly notify the Keystone Cares Foundation, in writing, of any material change to the information provided in this application. I agree that the Keystone Cares Foundation retains all rights to the Network Provider List and all the information provided therein, and in its sole discretion and without prior notice, the Keystone Cares Foundation may choose to exclude, modify, or delete information provided in the Network Provider List.
Signature

Powered by Jotform SignClear
Please note: The Keystone Cares Foundation reserves the right to refuse and/or discontinue a practitioner's listing on its website and referral list. Incusion or exclusion does not constitute endorsement, disapproval or liability on the part of the Keystone Cares Foundation, the Hart Grant Fund or its governing body. A practitioner being included in the resource database does not guarantee referrals to any clinic.
Please verify that you are human*
Should be Empty:

Keystone Cares Foundation