Contracting Physician Service Extender
(PA, CSA, CST, COT, CRNFA, OPA-C)
To be a contracting provider, the service extender must be employed and supervised by a licensed provider.
Submit the following items. Any missing items may result in the return of incomplete documents or a delay in processing.
- Current state license (attach a copy)
- Malpractice/liability insurance - minimum amounts of $1 million per occurrence, $3 million aggregate (attach a copy)
- Provider information sheet