Credentialing Survey

Please complete this form as this information will be used for credentialing, payer enrollment, and is part of the next phase of onboarding. Thank you!

Provider Information

Full Legal Name *

Former, Variations, or Aliases of your name: *

(Please include variations or aliases of your name that may be associated with your license, degree, or NPI. If none, please put NA)

Address *

Social Security Number *

Format 123-45-6789

Date of Birth

Country of Birth

State of Birth *

City of Birth *

Are you a US citizen? *

YesNo

Race/Ethnicity *

Mother's Maiden Name *

Gender *

What is Your Legal Sex? *

Sexual Orientation *

Are you Bilingual?

YesNo

Preferred Email *

Cell Phone Number *

Individual NPI # *

NPI/NPPES Username *

NPI/NPPES Password *

Primary Specialty *

Secondary Specialty (If Applicable)

Do you have a CAQH profile? *

YesNo

Education

Highest Degree Earned *

Please upload a copy of your highest degree earned *

or drag files here.

Graduate School Name *

Degree Obtained *

Graduate School Address *

Start Date (Approximate) *

End Date (Approximate) *

Undergraduate School Name *

Degree Obtained *

ECFMG Certificate # (If applicable) *

ECFMG Certificate # (If applicable)

Training

Training Type *

Licensure

Are you an Independently Licensed Provider? *

YesNo

Independently Licensed Providers do not require supervision

State Licenses

Please click the "Add Additional State License(s)" to add all licensures that you hold.

License Type *

(Example: MD, NP, PsyD, LCSW, LICSW, LMFT, LPC, etc.)

State Licensed In

State License # *

Upload A Copy Of Your License *

or drag files here.

Do you have a Medicaid Provider ID for this state? *

YesNo

Board Certifications

Are you Board Specialty Certified? *

YesNo

DEA

Do you currently have a DEA? *

YesNo

CDS

Do you currently have a CDS? *

YesNo

Do you have any additional certifications? *

YesNo

Professional Reference

Reference

Professional Reference Full Name *

Professional Reference Phone # *

Professional Reference Email *

Relationship to Reference *

(i.e. coworker, supervisor, etc.)

Number of Years Known *

Hospital Affiliations

Do you have any hospital affiliations? *

YesNo

Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated, or litigated)? *

YesNo

Additional Required Documents & Disclosure Questions

Please upload a copy of your Social Security Card: *

or drag files here.

Please upload a copy of your Driver's License: *

or drag files here.

Please upload a copy of your current CV in MM/YYYY Format: *

or drag files here.

Work History Gap

Please provide details for any gaps in work history below: *

If no gaps, please put NA

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Client Success

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Data Analytics

Credentialing Survey

Provider Information

Education

Training

Licensure

State Licenses

Board Certifications

DEA

CDS

Therapy

Professional Reference

Reference

Hospital Affiliations

Additional Required Documents & Disclosure Questions

Work History Gap

Disclosure Questions

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