Recredential: Application

Provider's Name*

First NameM.I.Last Name

California Acupuncture License Number*

Business Email*

Personal Email*

Clinic Phone Number*

Format: (000) 000-0000.

Personal Cell Number*

Format: (000) 000-0000.

Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Professional Status

All questions must be answered. All “YES” or “PENDING” answers must be explained below.

YesNoPending

1. If "Yes" or "Pending", please explain below*

YesNoPending

2. If "Yes" or "Pending", please explain below*

YesNoPending

3. If "Yes" or "Pending", please explain below*

YesNoPending

4. If "Yes" or "Pending", please explain below*

YesNoPending

5. If "Yes" or "Pending", please explain below*

YesNoPending

6. If "Yes" or "Pending", please explain below*

YesNoPending

7. If "Yes" or "Pending", please explain below*

YesNoPending

8. If "Yes" or "Pending", please explain below*

YesNo

9. If "No", please explain below*

Please Upload MALPRACTICE INSURANCE and OFFICE LIABILITY policy declarations pages.

Please Upload:

The Declaration page of your MALPRACTICE (Professional Liability) Insurance Policy.
o Please double check the expiration date of policy.
o The insurance limits must be at least 1 Million per Occurrence and 3 Million Aggregate

Malpractice Insurance Policy*

Please Upload:

The Declaration page of your Office Liability Insurance Policy.
o Please double check the expiration date of policy.
o The insurance limits must be at least 1 million per occurrence and 2 million Aggregate.

Office Liability Insurance Policy*

I hereby attest that the information I have provided in this application is current, correct and complete to the best of my knowledge and belief and in good faith. I understand that material omissions or misrepresentations may result in the denial of my application.

Provider's Signature*

(NOTE: Signature must be original. If Adobe Acrobat, the signature must be an original signature uploaded into Adobe)

Date*

Date

ShowFee

LateFee

Annual Renewal Subscription Fee

Processing Fee

Thank you for your application. Please note that the processing fee is non-refundable, as it helps cover the administrative costs associated with reviewing your submission. We appreciate your understanding and are happy to assist you with any other questions.

Total Amount Due

Re-Credential*

Annual Renewal Membership Fee

Renew Your Membership

$400.00

Processing Fee

Thank you for your application. Please note that the processing fee is non-refundable, as it helps cover the administrative costs associated with reviewing your submission. We appreciate your understanding and are happy to assist you with any other questions.

$15.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Re-credentialing Application

All questions must be answered. All “YES” or “PENDING” answers must be explained below.