Can this report be signed electronically?

Yes. Electronic signatures are legally equivalent under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are satisfied.

Is HIPAA compliance required for e-submission?

If the report contains protected health information, HIPAA applies and a Business Associate Agreement is required for covered entities under 45 CFR §164.502(e).

What happens if a license number is wrong?

Incorrect license data can delay credentialing and cause claims denials; verify with state licensing boards and correct via an amended report.

Are notarization or witnesses always needed?

Not always. Requirements vary by state and document purpose; use state-specific rules for attestations that require notarization or witness signatures.

How long must signed reports be kept?

Follow applicable federal and industry retention: IRS (3 years), HIPAA (6 years), SEC/broker rules (6 years) and longer where state law requires.

What authentication is recommended for signers?

Use at least email plus an access code; stronger authentication (SMS OTP, knowledge-based, or MFA) is recommended for PHI or high-risk attestations.

Electronic Signature
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Healthcare
Healthcare Practice Information Report

Healthcare Practice Information Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE PRACTICE INFORMATION REPORT

This Healthcare Practice Information Report is submitted to provide current administrative, clinical, billing and compliance information for the practice named below. All information provided must be true, complete and accurate to the best of the submitter's knowledge. Practice Name: Doing Business As:

Practice Identification

National Provider Identifier (NPI) Tax Identification (EIN or SSN) Legal Entity Type (select all that apply)

Corporation LLC Sole Proprietor Partnership Nonprofit Other:

Ownership / Parent Organization (if applicable)

Contact & Administrative Information

Primary Practice Address Mailing / Billing Address (if different)

Main Phone:

Billing Phone:

Practice Contact - Credentialing / Administrative

Billing & Insurance

Does the practice bill under the practice EIN or individual providers?

Insurance Accepted (check all that apply)

Medicare Medicaid Commercial / Managed Care Self-pay Workers' Compensation Other:

Billing Contact

Clinical Services & Capacity

Primary Specialties (check all that apply)

Cardiology Family Medicine Internal Medicine Pediatrics Orthopedics Other:

Ancillary Services Available

Laboratory Imaging / Radiology Pharmacy Physical Therapy Telemedicine Other:

Number of Exam Rooms:

Accepting New Patients: Yes No

Providers & Key Clinical Staff

List primary providers (up to five). Include name, NPI, specialty, license number and credential.

Provider 1 - Full Name

NPI:

Specialty:

License Number:

Credentials:

Accepting New Patients Provider 2 - Full Name

NPI:

Specialty:

License Number:

Credentials:

Accepting New Patients Provider 3 - Full Name

NPI:

Specialty:

License Number:

Credentials:

Accepting New Patients

Facility, Equipment & Accessibility

Facility Type (check all that apply)

Clinic Ambulatory Surgical Center Urgent Care Behavioral Health Other:

Key Equipment & On-site Capabilities Accessibility & Patient Services

Wheelchair accessible Interpreter services available Telehealth-enabled Other:

Compliance & Accreditation

Facility License Number License Expiration Date Accreditations / Certifications (check all that apply)

JCAHO AAAHC State Department Other:

Accreditation Expiration Date

Emergency Preparedness & Infection Control

The practice affirms it maintains written emergency response plans and infection control policies consistent with applicable law and standards. Indicate presence of plans and lead contact.

Emergency Preparedness Plan on File

Yes No

Emergency Contact / Preparedness Lead Infection Control Plan Summary

Confidentiality & Use of Information

Information submitted on this report may include proprietary or protected health information. The recipient will handle reported information in accordance with applicable privacy and confidentiality laws. Submission of this form authorizes the recipient to use the information for credentialing, contracting, network directory publication and related administrative functions. If reporting contains patient-level protected health information, include only minimum necessary data and mark accordingly.

Acknowledgment I acknowledge the confidentiality statement and attest that data submitted complies with applicable privacy laws.

Attestation & Certification

By signing below the authorized representative certifies, under penalty of civil liability, that the information contained in this report is accurate and complete. The practice agrees to notify the recipient in writing within thirty (30) days of any material changes to the information provided. Knowingly submitting false information may result in contractual remedies, administrative sanctions, or referral for civil penalties under applicable law.

Report Submitted By

Information valid through:

Authorized Representative (Print):

Title / Relationship:

Signature:

Date:

What the Healthcare Practice Information Report Is

The Healthcare Practice Information Report is a standardized record that captures core operational, licensing, payer, and compliance details for a medical practice. It typically includes practice legal name, tax identification, provider roster with NPI numbers, facility addresses, insurance contracts, credentialing status, and attestations about HIPAA and state licensing. Organizations use the report for credentialing, payer enrollment, audits, mergers, and internal compliance reviews. The format may be a fillable PDF, secure web form, or integrated record exported from practice management systems.

Why this report matters for compliance and operations

A complete Healthcare Practice Information Report centralizes credentials, payer details, and compliance attestations, reducing audit risk and accelerating payer enrollment. Where signed, it meets ESIGN/UETA standards for electronic records and must follow HIPAA safeguards for PHI handling under 45 CFR §164.530(j).

Who typically prepares and relies on the report

Typical users prepare, review, and accept Healthcare Practice Information Reports during credentialing, contracting, and compliance workflows.

Practice administrators and office managers who collect provider data and maintain operational records for the practice.
Credentialing and payer contracting teams that verify licenses, NPIs, and payer agreements for network enrollment.
Compliance officers and auditors who need consolidated attestations, HIPAA documentation, and change-history for inspections.

Different recipients use the report for enrollment, audit defense, contract approval, and internal recordkeeping.

Stepwise process to complete a Healthcare Practice Information Report

Follow a consistent sequence to gather data, verify credentials, and produce a signed, auditable report.

01

Collect data: Gather practice name, EIN, NPI, licenses, payer IDs, and facility addresses.
02

Verify credentials: Confirm license status, DEA registration, and malpractice coverage with primary sources.
03

Populate fields: Enter verified values into each required field using prescribed formats.
04

Sign and retain: Obtain required signatures, apply audit trail, and store per retention rules.

Basic digital workflow settings for online completion

Configure your e-submission workflow to protect PHI, capture intent, and create an audit trail.

Field	Configuration
Authentication	Email link or SMS OTP; stronger MFA for PHI recommended
Field Types	Text, date (MM/DD/YYYY), checkbox, numeric, file upload
Conditional Logic	Show payer fields only if practice accepts that payer
Audit Trail	Capture IP, timestamp, and signer attribution for each action

Technical and integration considerations

Integrating with EHR or practice management systems reduces rekeying and supports secure, auditable exchanges.

Integrations: Salesforce, NetSuite, Microsoft 365 and more
File formats: PDF/A, DOCX, and CSV exports supported
Authentication: Support for SSO and multi-factor authentication

Core sections to include in a professional report

A complete Healthcare Practice Information Report groups data into consistent sections to speed review and ensure compliance.

Practice Identity

Legal business name, DBA, business structure, and EIN — used to match tax and payer records during credentialing and contracting.

Provider Roster

Full list of clinicians with names, NPIs, state license numbers, DEA numbers, specialties, and credential expiration dates for credentialing checks.

Licenses & Credentials

State licenses, board certifications, malpractice carrier details and policy numbers, and effective/expiration dates for verification.

Payer & Contract Info

Payer IDs, accepted plans, effective contract dates, and billing addresses required for claims submission and payer enrollment.

Compliance Attestations

HIPAA privacy/security attestations, internal compliance officer name, and statements about current investigations or sanctions.

Facility Details

Practice addresses, service locations, contact numbers, and any CLIA or OSHA identifiers that affect licensing or inspections.

Security and compliance data points to record

Encryption in transit: TLS 1.2/1.3

Encryption at rest: AES-256

HIPAA capability: BAA available where required

Audit trail: Immutable timestamps and IP logs

Regulatory support: 21 CFR Part 11 compatibility

Certifications: SOC 2 Type II and ISO 27001

Key penalties and risks from incorrect or incomplete reports

1099 reporting: $60–$330 per form (IRC §6721)

Backup withholding: 24% withholding for missing/incorrect TIN

I-9 paperwork: $281–$2,789 per violation (8 CFR §274a.2)

HIPAA breach: Civil and corrective action risk for PHI disclosures

Licensure gaps: Denied claims, fines, or suspension

Contract delays: Payer enrollment or credentialing hold-ups

Practical tips to complete the report efficiently and accurately

Adopt repeatable checks and verification steps to reduce rework and avoid compliance lapses.

Use primary-source verification

Confirm license and NPI data with state licensing boards and NPPES to prevent credentialing denials and downstream claim rejections.

Standardize formats

Require MM/DD/YYYY for dates, two-letter state codes, and nine-digit EINs to prevent parsing errors during automated imports.

Attach supporting documents

Include copies of licenses, malpractice declarations, and payer letters with the report to speed reviewer approval and reduce follow-up requests.

Maintain version history

Keep an auditable change log and signed versions so you can demonstrate intent and the state of records at any point in time.

Representative eSignature vendor comparison for Healthcare Practice Information Reports

Compare baseline pricing and core capabilities; signNow appears first per vendor ordering requirements and supports HIPAA-capable plans.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Bulk Send	Yes (Premium)	Yes	Yes	Yes	Varied by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and common issues

Answers to typical questions about completion, signatures, retention, and legal validity for Healthcare Practice Information Reports.

Need help? Contact support

Can this report be signed electronically?
Yes. Electronic signatures are legally equivalent under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are satisfied.
Is HIPAA compliance required for e-submission?
If the report contains protected health information, HIPAA applies and a Business Associate Agreement is required for covered entities under 45 CFR §164.502(e).
What happens if a license number is wrong?
Incorrect license data can delay credentialing and cause claims denials; verify with state licensing boards and correct via an amended report.
Are notarization or witnesses always needed?
Not always. Requirements vary by state and document purpose; use state-specific rules for attestations that require notarization or witness signatures.
How long must signed reports be kept?
Follow applicable federal and industry retention: IRS (3 years), HIPAA (6 years), SEC/broker rules (6 years) and longer where state law requires.
What authentication is recommended for signers?
Use at least email plus an access code; stronger authentication (SMS OTP, knowledge-based, or MFA) is recommended for PHI or high-risk attestations.

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