New Psychologist Setup Form

Psychologist's Information

Below you will need to upload 1.) your License AND 2.) your Professional Liability Insurance.
Name*
First Last
Your Email*
Your Phone*
Your Date of Birth*
Your Social Security Number*
Your Gender*
- Male
- Female
Your Home Address*
Street Address Address Line 2 City State ZIP Code
Your Individual NPI #
Your Credentials (abbreviations)*
Your Taxonomy Code
Do you have a CAQH account set up yet?*
- Yes
- No
If yes, please list username and password:
Insurance Companies in network with
Please list the name of all the insurance companies that you were in network with at your last job.
What is the day you started working/will start at this new clinic?*
(First date treating patients)
MM slash DD slash YYYY
Upload your 1.) License AND 2.) Professional Liability Insurance*
Drop files here or

Max. file size: 256 MB.
Comments
This field is for validation purposes and should be left unchanged.