LETTER OF INTENT TO JOIN PCNO

Please use the following letter with your application to Primary Care of Northern Ohio (dba) Physician Consortium of Northern Ohio, Ltd.




Date

President/CEO
P. O. Box 276
Amherst, OH 44001

Dear          ,

This letter serves as a letter of intent to join Primary Care of Northern Ohio (dba) Physician Consortium of Northern Ohio, Ltd. Enclosed with this letter, is my completed CAQH form and the $300 application fee, which I understand will be applied to my annual dues.


Sincerely,


Name Here