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Chiropractic Provider Request Form

If you wish to participate with DPSC as a Chiropractor provider for the DPSC Network fill in the form below and submit.

DPSC does not charge an initial application fee. A 60.00 dollars credential fee is required for all Chiropractic delivery systems active providers. Do not send credentialing fee until requested by DPSC.

 

Name

Street

City State Zip

Phone Fax

Specialty   ID#

Email  

By Checking this box I indicate that I have read and agree to the terms at the top of this form and understand that if the application process proceeds there is a $60 Credential fee..


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Contact us at: D.P.S.C. Inc.  P.O. Box 731017 • Ormond Beach, Florida 32173-1017
Phone 386-615-0801   Fax 386-672-4811   e-mail: service@dpsc.info