SupDoc Facility/Clinic/Provider Supervision Request Form

Facility/Clinic/Provider Supervision Questionnaire
Please fill out the form below. The more information you are able to provide the quicker your contract can be created should you choose to move forward with suprvision. We have made this process very simple so that you have no disruptions in treating your patients or getting up and running. At the bottom of the form you will find a list of documents to send in to review for supervision to confirm your credentials. Should you not have one of those documents please contact us at the email below.

Thank you for chooosing Supervising Doc! We look forward to collaborating with you.
Facility or Clinic Name (Name of Business)
Facility/Clinic Name
How many providers or clinicians are you seeking supervision for?
Please enter the number of providers.
Website (if available)
My credentials are...

Nurse PractitionerPhysician AssistantRegistered NurseLicensed Vocational NursePsychiatric Mental Health Nurse PractitionerChiropractorOther
What type of practice or clinic do you have?

MedicalMental HealthCosmetic Aesthetics (Botox.Fillers, Laser Treatments)ChiropractorIV HydrationCryotherapyOther
Does you practice or medspa offer any integrative or alternative treatments? If so please explain.

YesNo
Please describe the off label or alternative treatments you offer.
Do you need assistance setting up an Allergan account or pharmacy account for standing orders?

YesNOI"d like more informationOther
Are you currently practicing with a client base?

YesNo
Do you need assistance with credentialing?

YesNoI would like more informationOther
Will you need Good Faith Exams (as required by your state and licensure?)

YesNoI would like more informationI'm not sure
Main Provider/Clinician Full Name

First NameLast Name
In what state are you licensed in?
State License Number
Facility or Clinic Address (If you are a mobile service provider please use the address registered to your legal business filing.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact Phone Number*
Main Contact Email Address*
example@example.com
Individual or Group NPI (if applicable)
Primary Taxonomy (If known) Skip if does not apply
Please list all states you currently hold a DEA certificate with. (If applicable, you do not need to list the DEA Numbers, only the states. You will be asked for a copy of the DEA certificates once you move forward with contract.
Do you have any other specialities or treatments you will be providing to patients or clients?
Please list here.
Malpractice Insurance Requirements

We require that all mid-levels and clinicians have their own malpractice insurance. The provider or clinician must also add their supervising physician to their policy as a third party insured, and must submit a copy of the policy within 48 hours of signing contract.
Do you currently have your own medical malpractice insurance?

YesNoWorking on obtaining policy.I need help or a referral for malpractice insurance.
Required Documents for Supervision Contract.

Below you will find a list of documents that are required to begin the contract. Once you have made the decision to move forward with supervision with Supervising Doc, you must send in the required documents with 72 hours. You will be provided with all of the information and licensing you need for you new Supervising Doctor. Please provide them in PDF or JPEG file. If you are unable to provide any of these documents you must contact our office by emailing support@supervisingdoc.com We will assist you.
- All Active Medical Licenses
- All Active Board Certifications
- All Active DEA Certifications (If Applicable)
- All Active ACSC or Controlled Substance Certifications)
- Continued Medical Education (CME's if available)
- Additional Certifications
- Certicicate of Malpractice Insurance
- Copy of your facility policies and procedures (If avaialble)
- DEA Certificates
By submitting this form I understand that I am not obligated to move forward to the next step. This form is an inquiry and collection of information to understand the type of supervision you need. I agree to submit all of the above documents should I move forward with supervision.

Yes
Name of person filling out this form.

First NameLast Name
Should be Empty:

Facility/Clinic/Provider Supervision Questionnaire

Malpractice Insurance Requirements

Required Documents for Supervision Contract.