Be sure to include the following information when submitting
completed application:
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A signed contract. |
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Completed and signed W-9 form. |
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Current state license information from all states in
which you practice. |
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All Board Certification information as requested on
application form. |
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Current workers' compensation certificate (if required
by your practice state) and/or worker's compensation questionnaire. |
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Copy of your current DEA certificate (if applicable). |
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Information as requested on application for any current
hospital affiliations and admitting privileges. |
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Malpractice Liability insurance coverage information
as requested on application. |
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Complete information as requested on application on
all past 5 years of malpractice history settlements and
information as requested on currently unsettled medical
malpractice claims. |
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Curriculum Vitae plus all relevant work history for
previous 5 years with month and years of employment. |
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All medical education & training programs from graduation
of medical school completed on application with start
and completion dates of each program. |
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All office locations and identify primary office location
and a credentialing office location and contact, if applicable
and different from primary office. |
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Any written explanations requested on the application
based on answers provided to questions about disciplinary
actions or malpractice history. |
