Healthcare Provider Application Form

Healthcare Provider Application Form

Please complete all sections of this application. Incomplete responses may delay processing. By signing this application the applicant certifies that all information provided is true, complete and correct to the best of the applicant’s knowledge and authorizes verification of any information supplied herein.

Provider Identifying Information

NPI:   Tax ID/EIN:   Date of Birth:

Gender: Male Female Non-binary Other

Contact Information

Licensure and Professional Identifiers

State Medical License #:   State of Issue:   Expiration Date:

DEA Number:   Medicare PTAN:   Medicaid ID:

Education, Training & Certification

Year of Graduation:   Residency:

Board Certified: Yes No   If certified, specialty and board:

Hospital Privileges & Practice Coverage

Malpractice Insurance & Claims History

Policy Number:   Limits of Liability:   Policy Expiration:

Have there been any malpractice claims, judgments, settlements, or pending suits in the past ten years? Yes No

Licensure/Disciplinary History

Has any licensing authority, professional organization, or peer review body ever limited, suspended, revoked, denied, or otherwise taken action against your license, privileges, or membership? Yes No

Practice Locations & Scheduling

Attachments Checklist

Attach the following documents as applicable: Curriculum Vitae Copy of Current State License DEA Certificate Board Certification Malpractice Declarations/Policy Face Sheet W-9 or tax documentation

Attestation, Authorization & Privacy Acknowledgement

Certification: I hereby certify, under penalty of perjury and to the best of my knowledge, that the information provided in this application and the accompanying documentation is true, complete and correct. I understand that any material misrepresentation or omission may be cause for adverse action, including denial of participation, termination, or recoupment of payments.

Authorization to Verify: I authorize all persons, institutions and entities to release to the requesting organization any information concerning my professional competence, character, health, liability claims, licensure, education, training, employment history and ability to perform professional duties. I release such persons, institutions and entities from any liability for their disclosure of such information.

HIPAA / Privacy Acknowledgement: I acknowledge receipt of the organization’s Notice of Privacy Practices describing the uses and disclosures of protected health information and my rights with respect to that information. I understand that this acknowledgement does not authorize any specific release of patient information beyond applicable law and contractual requirements.

Authorization Expiration: This authorization to obtain and disclose information is valid through unless earlier revoked in writing to the organization.

Final Declarations

I understand that submission of this application does not guarantee acceptance or credentialing. I agree to promptly notify the organization in writing of any changes to the information provided herein, including but not limited to changes in licensure status, malpractice coverage, or disciplinary actions.

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