National Med Licensing Intake Form

Please enter your Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Please enter your Email?*
example@example.com
Preferred Method of Contact
Gender*
What is your DOB?*

MonthDayYear
DOB
What is your Address?

Street Address

Street Address Line 2

CityState

Zip Code
How many years of experience do you have as a Nurse Practitioner?
What States Are you Currently Licensed in as a Nurse Practitioner?
Enter Your APRN License Number Below:
What's the Expiration Date of your APRN License?

MonthDayYear
Date
Please upload your APRN License below:

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Do you have your RN Compact License?*

YesNo
Enter Your RN Compact License Number Below:
What's the Expiration Date of your RN Compact License?

MonthDayYear
Date
Please upload your RN Compact License below:

Cancelof
Enter Your RN License Number Below:
What's the Expiration Date of your RN License?

MonthDayYear
Date
Please Upload Your RN License below:

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National Certification Type
What is Your Certification Number?
What is the Certification Expiration Date?

MonthDayYear
Date
Please Upload Your Board Certification Below:

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Please Upload Your Resume Below:

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Please Upload Your Driver's License or State ID Below:

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Any additional questions, preferences that you have?
Authorization & Consent*

I authorize National Med Licensing to assist in processing my state Nurse Practitioner license applications. I understand that this may involve the use and disclosure of my personal and professional information, including documents protected under HIPAA.
HIPAA Notice & Authorization to Disclose Information
By submitting this form, you acknowledge and consent to National Med Licensing collecting and using your personal health information (PHI), educational background, licensure data, and professional credentials for the purpose of state licensure application processing.

Your information will only be shared with authorized state licensing boards or affiliated regulatory agencies and will not be disclosed to unauthorized third parties. National Med Licensing will take reasonable precautions to protect your information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

You have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.
Electronic Signature*

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