NPI login information: (needed to file your Medicare application)
Do you have a complete CAQH Profile? Active, Discharged, Retired Military Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUCATION & TRAINING ENTRY
All Education & Training is shown on CV Do you want to list any Professional Associations? Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUCATION & TRAINING ENTRY
Board Certified (Primary Specialty)
Provide detailed items that are not contained on your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Again, DBN cannot begin your credentialing process without these details.
Are Complete Affiliation details including start/end date on your CV? Then please complete the information for each present and past hospital affiliation
Professional Licensure Information
Special Certifications (CPR, BLS, ACLS, etc)
Professional Liability Insurance
Provide insurance history for the last 10 years, or since you began practice if practicing less than 10 years. Provide information on any non-current policies for which you are not sending a copy of your Certificate of Insurance.
Do you have other coverage to report? Professional Experience
Provide detailed items that are not contained in your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Again, DBN cannot begin your credentialing process without these details.
We must have a minimum of 7 years of work history.
Is your complete work history shown on your CV? ATTESTATION QUESTIONS - All are required Licensure
Hospital Privileges and Other Affiliations
Education, Training and Board Certification
Medicare, Medicaid or other Governmental Program Participation
Other Sanctions or Investigations
Malpractice Claims History
"Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Feral law." The term does include, however, the unlawful use of prescription controlled substances.
You may upload the required document copies at this time to help speed up your application process. these documents are needed to complete your credentialing file so that we have all information necessary to provide you with enrollment services. Not all documents will apply to every practitioner.
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Required Documents Include: 1) Practitioner License(s)2) Malpractice Insurance (Certificate of Insurance)3) DEA (federal) and state CDS certificates4) Board Certification(s)5) Diploma - a copy of highest level of education (M.D., D.O, MSN, etc)6) Certificates of completion for all medical training (internship, residency, fellowship)7) Current copy of CV (showing current employer and MM/YYYY on all education and experience)8) IRS Form W-99) Current driver's license
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Other documents that may be applicable:1) ECFMG Certificate (if educated in a foreign country) 2) Passport or other citizenship documents (if born in another country)
Submit