Information you will be asked:
- Basic Personal Information
Education and Training
- Medical /Professional school
- Graduate school
- Internships and residencies
- Fellowships and preceptorships
- Teaching appointments
- Specialties and Board Certification
Practice Location Information
- Practice name and type
- Address and contact information
- Billing, office manager and credentialing contact
- Services, certifications, limitations and hours of operation
- Partners and covering colleagues
- Hospital Affiliation Information
- Malpractice Insurance Information
- Work History and References
- Disclosure and Malpractice History
Listed below are the required steps to complete your initial application:
- Register with the system.
- Complete all application questions.
- Complete any outstanding required fields.
- Review your application data summary.
- Authorize participating organizations access to your application data.
- Attest to your application data.
- Upload your supporting documentation.
Materials you will need to complete your application:
- IRS Form W-9(s)
- Drug Enforcement Administration (DEA) Certificate
- Controlled and Dangerous Substances (CDS) Certificate
- State medical license(s)
- Various identification numbers (UPIN, Medicare, Medicaid etc)
- Malpractice insurance policy(ies)
- Create a unique username (must contain at least 8 characters: combination of numbers and letters, and cannot contain special characters or spaces).
- Create a password (Passwords must be at least 8 characters and should not match your username.
- Select 3 Security Questions and answer.
- Agree to the Terms and Conditions.
- Select Create Account.