New Provider Info Form

CREDENTIALING LIST

These items must be emailed within 24-48 hours of this form being submitted. Please be sure to have them organized, prior to sending them in. Either one file or one email with multiple attachments is preferred.

If you are unable to provide any of the items, please send an email and let us know to the provided email.
Email them to info@onespotdoc.com
- Current Driver's License
- ALL Diplomas
- All Medical Licenses
- Board Certifications
- Resume
- DEA
- ACSC
- Residency and/or Internship Certifications
- Head shot
- CME's
- Certificate Of Insurance
- Curriculum Vitae (MUST HAVE MONTH AND YEAR)
NEW PROVIDER QUESTIONAIRE

WELCOME- WE LOOK FORWARD TO WORKING WITH YOU
Name*

First NameLast Name
Middle
Title*
SSN*
Place of Birth*
Email address*
example@example.com
Cell phone*
Date of Birth*

MonthDayYear
Date
Home Address*
City*
State*
ZIP*
LOCATION: if applicable
Specialty*
Sub Specialty*
Are you Board Certified?*
If yes, Which Board?*
If MidLevel, name of Supervising Physician*
Medical License State #*
DEA*
CDS
Medicare PTAN*
Individual NPI*
Medicaid*
Have you ever been convicted of a crime or had malpractice claim filed?*
If yes please give information
What is your license number? Multiple states--list with state postal abbreviation. i.e. Florida (FL) *
Social Media/Websites
Start Date (MM/DD/YYYY)
Should be Empty:

NEW PROVIDER QUESTIONAIRE