New Practitioner Form

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What date will practitioner start? *


Tax ID#: *




Last Name: *


First Name: *


Middle Initial:

Degree: *


Date of Birth:


Gender: *



DEA#: *


Medicaid#:


NPI#: *


Taxonomy Code: *


WI License Number: *


Credentialing Code:



Should practitioner be listed in Network Directory?  *

What specialty/specialties will practitioner be practicing? *


If practitioner is a Family Practice Practitioner,
does he/she do OB work? *

Practitioner Status? *













Will the practitioner be a PCP or Specialist? *




List all sites where practitioner will be practicing. If practicing at more than one site, list primary site first. *
Facility NameAddressCityStateZipPhone 
Add


What is the billing address for practitioner? *


What hospital(s) does practitioner have hospital admitting privileges at? *


Who backs up this practitioner when he or she is not available?

Is practitioner accepting new patients? *

What languages does practitioner fluently speak?



Whose attention should the credentialing application be sent to? *


Address: *


Phone: *


Fax: *


Email:  

Comments:  



Completed By: *

Email Address: *



 


* Indicates a required field.