Participate in Our Network
We make it easy for you to work with us

Be sure to include the following information when submitting completed application:

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

Please remember that sending in an application does not automatically make you a network participant. Please see the Summary of Credentialing Standards.