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Please mail completed application packets (original signatures) to the Children’s System of Care as instructed in the materials below.

Please include a copy of your resume, credentials and certificates obtained that are relevant to any listed specializations.

Click HERE to view guidelines for filling out the IIC Provider application.

  1. IIC Application Cover Letter 
  2. Notice to Enrollee(s) 
  3. Request for National Provider Identifier (NPI) 
  4. Signature Authorization Form 
  5. Provider Application-FD-20 
  6. Provider Agreement-FD-62 
  7. Disclosure of Ownership and Control Interest Statement
  8. W-9 Tax Form  
  9. Affirmative Action Survey (Optional) 
  10. Authorization of Automatic Payments & Deposits 
  11. Agreement of Understanding 
  12. Provider Profile Information Form