Document Upload
Required Documents:
Core Documents for an individual
Core Documents for an individual
- Practitioner License(s)
- Malpractice Insurance (Certificate of Insurance)
- DEA (federal) and state CDS certificates
- Board Certification(s)
- Diploma - copy of highest level of education (M.D., D.O, etc)
- Certificates of completion for all medical training (intership, residency, fellowship)
- Current copy of CV (showing current employer)
- IRS Form W-9
- Current driver's license
- Malpractice Insurance (Certificate of Insurance)
Other documents that may be applicable:
- ECFMG Certificate (if educated in foreign country)
- Passport or other citizenship documents (if born in another country)
Documents needed for your legal entity:
- IRS form CP575 or replacement letter 147C (verification of EIN)
- CLIA Certificate
- Business License
Use the form below to upload your documents to our server. This form uses Adobe Flash. You may click the "Choose Files" button to browse your computer to select files, or you may drag and drop files into the box below. If you need a non-flash form, please click here.
