It is important to complete each section of the application and provide all required documents listed below:

 

MYidealDOCTOR Application Packet Includes:
 

◻   FAQ’s

◻   Credentialing Application

◻   Background Disclosure and Authorization Forms

◻   Direct Deposit Form

◻   W-9 Form

 

◻   Depending on your state license(s) additional Credentialing Applications and/or Contractor Agreements are required and will be attached separate from the application packet.

 

Remember when completing your application:
 

◻   Under Work History- you must have dates of employment and correct contact information

◻   2 Peer References must be a MD or DO and must have correct fax or email address

 

Provide Supporting Documents
 

Please submit all supporting documents in one PDF to assist credentialing in accelerating the process.

 

◻   Current Curriculum Vitae (CV) MM/YY Format

◻   Active State License Certificate(s)

◻   Drug Enforcement Agency Certificate (DEA) with expiration date

◻   Board Certification(s) (MYidealDOCTOR REQUIRES Board Certification under ABMS).

 

◻   Voided Check

◻   Profile Photo- Headshot Preferred

 

 

 

 

   Physician FAQ

Q: What is MYidealDOCTOR?
 

A: MYidealDOCTOR is a network of licensed primary care physicians who diagnose routine, non-emergency medical problems via the telephone and/or video. MYidealDOCTOR consulting physicians recommend treatment and prescribe medication (when appropriate) over the telephone and/or video 24 hours a day, 365 days a year to patients.
Q: What is the age range of the patients I will perform consults for?

 

A: MYidealDOCTOR provides services to patients starting at the age of 2 years old. MYidealDOCTOR and the Physician determine the best age ranges for the Doctor to treat based upon the physician’s comfort level and the physician’s current practice age population.

Q: What is MYidealDOCTOR membership base?

 

A: MYidealDOCTOR offers services to both large and small corporations, unions, third party administrators, Insurance Companies, and the retail market.

 

Q: If I elect to join MYidealDOCTOR, will I be considered a MYidealDOCTOR full time employee?

 

A: No. Each physician accepted to join the MYidealDOCTOR is hired as a contract employee through MYidealDOCTOR, LLC.  All contract employees receive a 1099 annually.

Q: Does MYidealDOCTOR have set schedules?

 

A: Currently MYidealDOCTOR is able to allow physicians to work their own available hours.

Q: Does MYidealDOCTOR provide follow-up care?

 

A: No. If follow-up care is required, the physician will recommend the patient see a primary care physician or visit an urgent care setting.

 

Q: Does MYidealDOCTOR offer Medical Malpractice Insurance? Does it include tail coverage?

 

A: Yes. MYidealDOCTOR offers coverage up to $1,000,000.00 per incident and is capped at a total of $3 million. This insurance is provided free of charge for services rendered for MYidealDOCTOR only.

 

Q: Do I have access to the electronic medical record (EMR)?

 

A: Yes. MYidealDOCTOR requires each patient complete a medical history disclosure prior to consult.

 

Q: How long is a typical consult? What is the compensation per consult?

 

A: The average consult takes between 8 and 10 minutes to complete with the reimbursement rate of $25.00 per completed phone consult and per completed video consult.

MYidealDOCTOR CREDENTIALING APPLICATION

 

CREDENTIALING OFFICE PHONE: 478-412-5054 – CREDENTIALING DIRECTOR MOBILE 229-393-0624
FAX: (800) 794-9023

By completing an Application for employment/contract labor to the Staff of MYidealDOCTOR, I…:

·       Signify my willingness for interviews concerning this application;

·       Fully understand and agree that I have the burden of producing adequate information for the proper evaluation of my professional current competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I hereby reaffirm that I will abide by the Credentialing Policies and Procedures/Rules and Regulations;

·       Consent to the inspection and copying of all records and documents that may be relevant to my pending credentialing/employment review and decision;

·       Release MYidealDOCTOR, it’s officers, directors, employees, representatives, agents, and the Credentialing staff from any liability for acts performed in connection with the processing and evaluation of this application and from any and all consequences resulting from the disclosure of the information;

·       Unless otherwise prohibited by state or federal law, release the Credentialing staff and MYidealDOCTOR employees or representatives and authorize them/consent to provide other hospitals, licensing boards, and organizations concerned with my performance and the quality of patient care, relevant information that MYidealDOCTOR may have concerning my performance or quality of patient care;

·       Consent to the confirmation of current physical and mental health status to perform the duties necessary in the manner as required by MYidealDOCTOR and as stated in the Credentialing Plan/Policies and Procedures. (A copy of these documents is available for review upon request to the Credentialing office at MYidealDOCTOR)

·       I authorize any third party including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care services, medical credentialing and accreditation agencies, professional medical societies, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to MYidealDOCTOR and/or its Agent(s), information including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualification for participation in, or with, MYidealDOCTOR. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release;

·       I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of MYidealDOCTOR its Agent(s), or other third party in connection with the gathering, release and exchange or, and reliance upon, information used in accordance with this Authorization, Attestation and Release, I further agree not to sue any Entity, any Agent(s) or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity,

 

Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by laws for peer review and credentialing activities;

·       In this Authorization, Attestation and Release, all reference to MYidealDOCTOR, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. MYidealDOCTOR,  or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement.

·       I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation, a member of MYidealDOCTOR,  health care staff, or a participating provider of MYidealDOCTOR,. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by MYidealDOCTOR, in accordance with the applicable rule and regulation and requirements of MYidealDOCTOR, or grounds for my termination of Participation at or with MYidealDOCTOR,. I agree that information obtained in accordance with the provisions of the Authorization, Attestation and Release is not and will not be a violation of my privacy.

·       I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify MYidealDOCTOR,  and/or its Agent(s) within 30 days of any material changes to the information I have provided in my application or authorized to the release pursuant to the credentialing process.  I understand that corrections to the application are permitted at any time prior to a determination of Participation by MYidealDOCTOR,, must be submitted on-line or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination. This action may be disclosed to MYidealDOCTOR, and/or its Agent(s).

·       I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

 

I acknowledge and attest that the information contained in this application, and all enclosed attached documents I agree to provide to support this application, are complete and accurate. I agree to notify MYidealDOCTOR, of any change in the information contained in this application and any attached documents within thirty (30) days of the date that I am, or should be, made aware of the change.

 

 

I hereby consent to, authorize, and release from liability CAQH, its agents, and CAQH affiliated vendors
to release access to my application data, as it relates to the completion and maintenance of the provider
credentialing data contained therein, as long as this information is provided in good faith and without
malice, unless such acts are due to the gross negligence or willful misconduct of CAQH, its agents, and
any CAQH affiliated vendors, to:

1. Felicia Morris (Primary Authorized Contact Name) of MYidealDOCTOR
(Primary Authorized Contact Organization/Practice Name), who may be reached at
855-879-4332 (Primary Authorized Contact Information).

and/or

2. Adrian Davis (Secondary Authorized Contact Name) of MYidealDOCTOR (Secondary Authorized
Contact Organization/Practice Name), who may be reached at 855-879-4332 (Secondary Authorized Contact Information).

Of the information to be released, to the delegated authorized party (or parties) as specified above, includes my CAQH Provider ID number, CAQH ProView Username, and Primary Method of Contact.

I understand that a photocopy or facsimile of this Authorization and Release form shall be as effective as
the original when so presented, unless canceled by me in writing.

 

(Providers please note, if an expiration date is not included, you letter will expire three years from the date
the letter was received by CAQH.)

If you do not know your CAQH Username and/or Password please contact your credentialing department at your current location .

CAQH is a credentialing database we use to verify your information during our on boarding for new physicians with MYidealDOCTOR, LLC.

Printed Name of Provider

MYidealDOCTOR, LLC

Felicia Morris

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

MYidealDOCTOR (“the Company”) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. Credit history will not be requested. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

 

 
I have attached a voided personalized check (checking accounts) or deposit slip (savings accounts) for each account specified. (This request will not be processed without the accompanying documentation.)

 

I hereby authorize the Company to directly deposit any salary or wages due to me, less any mandatory or authorized withholdings or deductions in the bank account(s) listed above in the percentages specified. (If two or more accounts are designated, deposits are to be made in whole percentages of pay to total 100%.)

 

The Company will credit my account(s) the amount of my payroll check on payday. The Company will provide me with a check stub on payday listing my deductions and pay. I understand that direct deposit is contingent each pay period on timely receipt of payroll hours and timely receipt of payroll funding from the client I am assigned to. Deposits are normally available the morning of pay date however each bank posts funds to accounts at different times daily, and the Company has no control over my bank’s posting.

 

Also, I hereby grant the Company the right to correct any such electronic funds transfer resulting from an erroneous overpayment by debiting my account to the extent of such overpayment.

 

I authorize my financial institution to accept direct deposits to my account upon receipt and without advice to me. It is my responsibility to verify deposits on a per pay date basis before writing checks against these funds. I understand that the Company is not responsible for bank errors or bank fees. Banking services are provided in accordance with the limitations and restrictions of the Automated Clearing House Association.

 

This authorization is to remain in force until the Company has received written authorization from me of its termination or change. I understand that if my account has closed, my financial institution cannot accept a deposit on my behalf. If this occurs, my employer will not be able to process any further direct deposits without further written authorization from me. IN ORDER TO TERMINATE OR REVOKE THIS AUTHORIZATION, I MUST NOTIFY MY EMPLOYER IN WRITING AT LEAST TWO WEEKS PRIOR TO THE TERMINATION.