Provider Onboarding

Step 1 of 4

25%

Your Personal Information

Your Name

First Last

Your Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone

Best Time To Call You

When is the best time for us to reach you via telephone?

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

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

More About You

NPI number

State License Number(s)

DEA Number

FAWM Status

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

Have you voluntarily surrendered, limited, or withdrawn your application for appointment, or reappointment of any clinical privileges or resigned from the medical staff of any healthcare facility while a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

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

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

Has your Federal DEA registration or DPS Controlled Substances Certificate(s) or authorizations been investigated, suspended, limited, revoked, or voluntarily relinquished?(Required)

Yes

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

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

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

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

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

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

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

Filings

Please upload any filings received as per previous question.

Drop files here or

Max. file size: 25 MB, Max. files: 5.