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Provider Onboarding
Provider Onboarding
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Your Personal Information
Your Name
First
Last
Your Email Address
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Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Your Phone
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Mornings
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Hours You Are Available for Work
Please tell us what hours you are available for work each day of the week.
Monday
Tuesday
Wednesday
Thursday
Friday
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Previous Employment
Previous/Current Provider Jobs You've Held
Please list your previous employers, the dates you worked and the position you held
Employer
Dates
Position
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More About You
NPI number
State License Number(s)
DEA Number
FAWM Status
Eligible
Enrolled
Diplomate
Upload Your CV
Upload your CV in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.
Upload Your Medical School Diploma
Upload your Diploma in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.
Upload Your DD214
Upload your DD214 (if you have one) in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.
Has your license to practice (MD, DO, RN, EMS, PA, etc.) in any clinical capacity (current or prior), ever been reviewed, investigated, denied, suspended, revoked, restricted, voluntarily surrendered, or have you been subject to a consent order, probation, reprimand, fine, or any conditions or limitations by any state licensing board (Board of Medicine, Board of Nursing, Department of Health, etc.)?
(Required)
Yes
No
Have you voluntarily surrendered, limited, or withdrawn your application for appointment, or reappointment of any clinical privileges or resigned from the medical staff of any healthcare facility while a disciplinary action or decision regarding your privileges status was under investigation?
(Required)
Yes
No
Have you been excluded, suspended, sanctioned, terminated, debarred, reprimanded, censured, disqualified, been subject to any disciplinary action, or otherwise restricted from participating in any federal or state program or any private health insurance program (i.e. Medicare, Medicaid, Blue Cross, etc.)?
(Required)
Yes
No
Have you been the subject of any investigation or disciplinary proceedings (suspended, denied, limited, revoked, not renewed, etc.) at any healthcare facility or by any medical organization?
(Required)
Yes
No
Has your Federal DEA registration or DPS Controlled Substances Certificate(s) or authorizations been investigated, suspended, limited, revoked, or voluntarily relinquished?
(Required)
Yes
No
Have you been involved in any civil proceedings involving allegations that you engaged in sexual or racial harassment or allegations that you engaged in acts of racism?
(Required)
Yes
No
Have there been any misdemeanor, felony, or other criminal charges brought against you, including conviction, pled guilty to, pled nolo contendere, probation, deferred adjudication, or that were reduced to a lesser charge or subsequently dropped, or that are currently pending (not including minor traffic violations such as speeding, illegal parking, failure to stop, running a red light, etc.)?
(Required)
Yes
No
Is there any reason that you cannot perform all of the professional clinical duties that would be required of you in this position?
(Required)
Yes
No
Have you ever been evaluated for, recommended for treatment of, diagnosed with, or treated for alcohol, opioid, or any substance abuse, sexual addiction, or anger management?
(Required)
Yes
No
Have you been evaluated for, recommended for treatment of, diagnosed with, or treated for any mental illness that may affect your ability to perform the duties of the position applied for (i.e., major depression, psychoses)?
(Required)
Yes
No
Are there any pending investigations/matters with any hospital, licensing authority, DEA, DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal, or state health program, or Criminal Law Authority?
(Required)
Yes
No
Have any professional liability claims, suits, arbitrations, or other proceedings been filed against or to you, or have you received any notice of any such filing? Please include all such filings, regardless of outcome in the next question.
(Required)
Yes
No
Filings
Please upload any filings received as per previous question.
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Max. file size: 25 MB, Max. files: 5.