CREDENTIALING INFORMATION FORM: Physician
How did you find out about MD Reimbursment Associates?
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Physician Referral
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First Name
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Middle Name
Last Name
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Degree
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Street Address
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City
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State
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Zip Code:
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Phone Number
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Email
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example@example.com
Date Of Birth
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Month
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Day
Year
Date
City & Country of Birth
Professional Data
State License #
DEA #
SSN #
MEDICAID #
MEDICARE #
NPI #
CDS #
Primary Specialty
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Board Certified
Board Eligible
Name of Certifying Board
Date of Certification
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Month
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Day
Year
Date
Expiration Date
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Month
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Day
Year
Date
Sub-Specialty
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Board Certified
Board Eligible
Name of Certifying Board
Date of Certification
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Month
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Day
Year
Date
Expiration Date
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Month
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Day
Year
Date
Are there any age limitations
Yes
No
Do you currently have hospital admitting privileges? (If more than one hospital, indicate primary)
Yes
No
Min/Max Age Limitation:
Hospital Name and Address
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