Core Documents for an individuals:

Physicians:

  1. Practitioner License(s)*
  2. Malpractice Insurance (Certificate of Insurance)*
  3. DEA (federal) and state CSR certificates (if applicable)
  4. Board Certification(s) (if applicable)
  5. Diploma – copy of highest level of education (M.D., D.O, etc)
  6. ECFMG Certificate (required if educated outside of The United States)
  7. Certificates of completion for all medical training (internship, residency, fellowship)
  8. Current copy of CV (showing current employer)*
  9. Current driver’s license*

Mid-Level Providers, Therapists, and other healthcare providers:

  1. Practitioner License(s)*
  2. Malpractice Insurance (Certificate of Insurance)*
  3. DEA (federal) and state CSR certificates (if applicable)
  4. Board Certification(s) *
  5. Diploma – copy of highest level of education¬†(Master’s degree, PA, DPT, etc)*
  6. Current copy of CV (showing current employer)*
  7. Collaborative Agreement * (required for NP’s)
  8. Supervising Physician Agreement * (required for PA’s)
  9. Current driver’s license*

Other documents that may be applicable:

  1. Passport or other citizenship documents (if born outside U.S. and not previously enrolled in Medicare)
  2. Admitting Arrangement letter (required for providers who do not have hospital admitting privileges)
  3. Prescribing Arrangement Letter (required if you do not have a DEA certificate)

Documents needed for your legal entity:

  1. IRS Form W-9*
  2. IRS form CP575 or replacement letter 147C (verification of EIN)*
  3. CLIA Certificate (if applicable)
  4. Business License (if applicable to your area)
  5. Fictitious Name Permit (if applicable in your area)
  6. Copy of office lease (required for independent therapy facilities to enroll with Medicare)

*Required