Application for Provider Participation

The following is a confidential application form. This should be filled out entirely and sent to Opticare Vision Services -1901 W. Parkway Blvd. Salt Lake City, UT 84119. With the application, please enclose one copy of the following: (For additional doctors, copy and fill out sections 2 through 4)

• Professional license and/or board certifications (one for each doctor being listed)
• Current Malpractice Insurance certificate (one for each doctor being listed)
• Controlled Substance registration certificate (if applicable)
• Business license(s)
• W-9 form
• Fee Schedule (signed by the owner)
• Agreement (signed by the owner)