Credentialing Questionnaire - Medical Billing and Practice Management

Required Documents you will need to submit: State License(s), DEA (if applicable), Certificate of Insurance liability, W9, and IRS EIN form
Provider Type:
Provider Name:
First Middle Last
Current home address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone number:
Fax number:

Internship/Post-Graduate/Professional Training (if applicable):
You may make additional copies, if needed.
Dates to
Month
Day
Year
Dates from:
Month
Day
Year
Institution name:
Type of program/Specialty:
Completed training:
- Yes
- No
Expected completion date:
Month
Day
Year
If not successfully completed, explain:
Name
First Last
Program Director:
Phone
Email

Chronological Employment/Practice History
List all experience, including military service and public health, sabbaticals, personal travel, etc. LEAVE NO GAPS IN CHRONOLOGY.
From:
Month
Day
Year
To:
Month
Day
Year
Organization Name:
Title/Position:
Reason for leaving:
Contact name:
Clinic still open?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Life support certification (BLS, ACLS, ATLS, etc)?
- Yes
- No
Liability Insurance:
Coverage dates:
Month
Day
Year
Start
Coverage dates:
Month
Day
Year
Expire
Current Carrier Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax:
Email
Policy Number:
Amount of Coverage per occurrence:
Amount of Coverage per aggregate:
Add another policy?
- Yes
- No
Please add as needed to include all policies that you have held in the past 10 years, including policies covering Residencies and Fellowships.
Policy Number:
Amount of Coverage per occurrence:
Amount of Coverage per aggregate:
Tax ID
Required Documents you will need to submit: State License(s), DEA (if applicable), Certificate of Insurance liability, W9, and IRS EIN form*
You can find a blank W9: HERE
Drop files here or

Max. file size: 100 MB.
If certified in any Specialty, please enclose a copy of certification.
Please Upload Any Other Relevant Information
Drop files here or

Max. file size: 100 MB, Max. files: 5.
Phone
This field is for validation purposes and should be left unchanged.

Undergraduate