Provider Application

Licensed Provider Application

Psychiatric NPs/PAs and Therapists
Full Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What position are you applying for?
Are you looking for part-time or full-time hours?
Professional Title/Credentials
What days and hours can you see patients?
Are you currently credentialed with any insurance plans/which ones?
NPI Number
CAQH Number and login info (if available)
Medicare Number (s) and States (or N/A)
Social Security #
List all states you hold professional licenses?
Upload copy of all state license certificates/online verifications

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Collaborating Physicians/Which States (N/A if not applicable)?
Upload copy of collaborating physician agreements (if applicable)

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Do you have any professional license restrictions, suspensions, or revocations? Barred from insurance plans or credentialing?
List DEA Numbers and States (If applicable)
Upload copy of DEA certificates

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Available start date:

MonthDayYear
What is your current employment status?
Upload Your Resume

Upload a File

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Are you legally authorized to work in the U.S?
Upload Drivers License/State ID

Upload a File

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Upload Copy of current malpractice insurance

Upload a File

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Malpractice policy expiration date

MonthDayYear
Date
Upload Headshot for marketing purposes

Upload a File

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Provide Short Professional Bio of Specialty/Experience
Experience
Your Position?
Company Name?
Dates
Job Description
Reason For Leaving
Experience
Your position?
Company Name
Dates
Job Description
Reason For Leaving
Experience
What was your position?
Dates
Company Name
Job Description
Reason For Leaving
Experience
What was your position?
Company Name
Dates
Job Description
Reason For Leaving
Education
Undergraduate Program/Degree
Graduate Program/Degree
Other Educational Program/Training
Upload Diploma

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Upload Psych Board Certificate or other certification?

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Specialized Training/Software/Skills
I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated.
Signature
Date

MonthDayYear
Date
Should be Empty:

Licensed Provider Application

Experience

Experience

Experience

Experience

Education