Let’s work together.

Name

First Name

Last Name

Profession / Occupation

Subject

Message

Mobile Phone

(###)

###

####

NPI#

Required for all billing providers: MD/DO, NP/PA. Enter 'N/A' if not applicable for your role.

Specialty (list all)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

State Licenses

Please list ALL active, and retired state licenses.

Are you enrolled with the IMLC (Interstate Medical Licensure Compact) and have a Valid LOQ (Letter of Qualification)

If you are not enrolled in IMLC, enter 'N/A'

Medical License number of the SPL (State of Principal License) (required)

IMLC LOQ holders only. Enter 'N/A' if you do not have IMLC

Date of last NPDB Self-Query

Please provide the date your last NPDB self-query. If you do not have this information, please request one: https://www.npdb.hrsa.gov/ext/selfquery/SQHome.jsp

YYYY

Summary of NPDB self-query

Please provide a succinct summary of your last NPDB self-query (if applicable), and identify if there were any lawsuits, sanctions, or malpractice settlements within the last 10 years. If yes, please provide as much context and detail as possible.

Your Availability

Please tell us what capacity you have for working with us (FT / PT), and when you are looking to start.

Please list all EMRs you have experience with.

Professional Reference

Please provide a peer reference that has worked with you within the last 3 years. Include (1) Full Legal Name, (2) Specialty, (3) Email, and (4) Phone number.

Professional Reference

Please provide a peer reference that has worked with you within the last 3 years. Include (1) Full Legal Name, (2) Specialty, (3) Email, and (4) Phone number.

Professional Reference

Please provide a peer reference that has worked with you within the last 3 years. Include (1) Full Legal Name, (2) Specialty, (3) Email, and (4) Phone number.

Let’s work together.

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