Doctor Profile and Intent to ParticipateMUST BE COMPLETED BY EACH DOCTOR AT PRACTICEName First Last Email Individual NPICAQHPlease check all that apply YES, I am willing to participate in contracts secured and managed by Coherent Eye Care, LLC You may use my name on a Potential Provider DirectoryConfidentialityAs a participant with Coherent Eye Care, LLC any managed care or third party contracting information shared with me on behalf of said programs and myself is to remain confidential. This includes information received by any source including, but not limited to, pricing, negotiations, meetings, written information, other members, vendors, representatives or prospective members. Any information that concerns or pertains to the managed care contract in question (regardless of its nature) is to remain confidential even if my relationship with Coherent Eye Care, LLC were to cease.TerminationI understand that this Letter of Intent will automatically terminate on the anniversary of the Effective Date of the current contract I am being recruited to participate in. If I decide to withdraw from the panel earlier than this Effective Date, I agree to provide 30 days written notification. I understand that a Provider Agreement will be provided upon receipt of this executed Letter of Intent to Participate and will replace this Letter of Intent once executed.SignatureDate MM slash DD slash YYYY MUST BE COMPLETED BY EACH DOCTOR AT PRACTICEName First Last Email Individual NPICAQHPlease check all that apply YES, I am willing to participate in contracts secured and managed by Coherent Eye Care, LLC You may use my name on a Potential Provider DirectoryConfidentialityAs a participant with Coherent Eye Care, LLC any managed care or third party contracting information shared with me on behalf of said programs and myself is to remain confidential. This includes information received by any source including, but not limited to, pricing, negotiations, meetings, written information, other members, vendors, representatives or prospective members. Any information that concerns or pertains to the managed care contract in question (regardless of its nature) is to remain confidential even if my relationship with Coherent Eye Care, LLC were to cease.TerminationI understand that this Letter of Intent will automatically terminate on the anniversary of the Effective Date of the current contract I am being recruited to participate in. If I decide to withdraw from the panel earlier than this Effective Date, I agree to provide 30 days written notification. I understand that a Provider Agreement will be provided upon receipt of this executed Letter of Intent to Participate and will replace this Letter of Intent once executed.SignatureDate MM slash DD slash YYYY
