LETTER OF INTENT TO JOIN PCNO

Please use the following letter with your application to Primary Care of Northern Ohio.




Date

President/CEO
221 W. 21st St.
Lorain, OH 44052

Dear          ,

This letter serves as a letter of intent to join Primary Care of Northern Ohio. 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

Primary Care of Northern Ohio, Ltd.     221 W. 21st Street Suite 8     Lorain, OH 44052     (440) 233-1073