If you are interested in becoming a provider, please contact Sue Garcia, Network Coordinator at (719) 634-1825 or 1-800-645-6571 to request our provider forms. Please fill out the forms and submit with the paperwork listed below. All paperwork must be completed and returned to our network coordinator.

1. Provider Application, signed Statement of Understanding and W-9.
2. Two Affiliate Agreements signed. (One will be returned to you).
3. Copy of State license(s) with expiration date clearly visible on the copy.
4. Proof of Professional Malpractice Insurance with dates of expiration.
5. Resume including education, post-graduate training, and professional experience.

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