Medical Provider Application

Medical Provider Application
Legal Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Select Your Specialty*
Please Specify Your Specialty
Required Credentialing Documentation

Please upload each required document in the appropriate section.
Driver's License (front and back)*

Cancelof
Resume/CV Upload*

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Proof of Active Provider Certification*

Cancelof
Proof of Active State License(s)*

Cancelof
Proof of DEA Registration*

Cancelof
Proof of Personal General Liability Coverage*

Min. $1,000,000/$2,000,000
Cancelof
Expiration Date of Provider Liability Insurance*

MonthDayYear
Date
Proof of Active Basic Life Support (BLS) Certificate*

Cancelof
Expiration Date of BLS*

MonthDayYear
Date
Proof of Active Advanced Cardiovascular Life Support (ACLS) Certificate*

Cancelof
Disclaimer
By signing this form, I confirm that the information provided is true and accurate to the best of my knowledge. I also hereby authorize Kings Medical Services/Checkmate Health Technologies to initiate a background check as part of the credentialing process. I understand that a separate link will be sent to complete the background check. I acknowledge that failure to provide accurate information or to consent to the background check may result in disqualification from consideration as a provider.ated.
Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

Medical Provider Application

Required Credentialing Documentation

Disclaimer