Before you begin, please indicate with an X if you are submitting a Request with Interest in Participating in our Preferred Care Plan.
Please note: This is not an Agreement or a Contract. This is a Request for consideration to become a provider in Kare KONEC Provider Network, which will be reviewed for consideration. This does not guarantee payment or an effective date of being in the Kare KONEC Provider Network.
If the request is approved, you will receive contracts, and credentialing is required. Until you are credentialed, contracted, and notified that you are in the Kare KONEC Provider Network as a participating provider, you are considered out -of- network. All out-of-network providers require authorization to provide care to Kare KONEC members. Services provided without authorization will be denied. Your effective date for participation is not based upon submission of this request, it will be based solely upon your credentialing and contracting, if, when, approved.
Legal Notices: Future notices, contract-related documents, and legal communications will be in writing and submitted to the following Provider Chief Financial Officer (CFO) or other Provider Contracting Contact and mailing address
Provider Information (if Group request, including all Providers in the Group): provide an extra sheet if necessary.
*Please provide your specialty- this is very important.
*Physicians must have hospital admitting privileges at a Kare KONEC contracted hospital or must provide an explanation of arrangements in place for members to be admitted to a Plan participating hospital. The provider offer any special services.