Healthcare Doctor Detail Form

Healthcare Doctor Detail Form

Doctor Identification

NPI Number:    Specialty:

Medical License No.:    State:

License Issue Date:    Expiration Date:

Contact & Practice Address

Office phone:    Fax:

Professional Education & Training

Residency:    Year completed:

Credentials, Board Certification & Privileges

Yes    No

Insurance & Malpractice

Policy number:    Coverage limits:

Policy effective date:    Expiration date:

Yes    No

Practice Operations & Availability

Languages spoken:

Accepting new patients: Yes    No

Telemedicine services offered: Yes    No

Authorization & Compliance

By signing below, I hereby attest that the information provided on this form is true, complete, and accurate to the best of my knowledge. I authorize the release of credentialing, licensing, and malpractice information to the requesting facility or payer for the purpose of credentialing, privileging, and quality assurance. I understand that falsification, omission, or misrepresentation of material facts may result in denial, revocation, or termination of appointment or privileges and may be subject to civil or criminal penalties.

I acknowledge that I will comply with all applicable federal and state laws, including those governing patient privacy and the protection of health information. I further certify that I have not been excluded from participation in federally funded health care programs and will notify the facility immediately should my status change.

HIPAA / Privacy acknowledgement: I acknowledge receipt of applicable privacy and security policies and agree to comply with those policies in the handling of protected health information.

Additional Information

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