(423) 443-4525

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. ECFMG Certificate (required if educated outside of The United States)*
  6. Fellowship Certificate of Completion (if applicable)*
  7. Current copy of CV (showing current employer)*
  8. Current driver’s license*

Mid-Level Providers (NP, PA, etc), Therapists (PT, OT, SLP, etc), 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 practicing in states with less than “Full Practice” practice environments)
  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 in order to contract with commercial insurance networks
  3. Prescribing Arrangement Letter = required for providers who will not have prescribing authority with DEA and/or CSR in order to contract with commercial insurance carriers.

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) – required in CA
  6. Copy of office lease (required for independent therapy facilities to enroll with Medicare)
  7. Bank account verification – either pre-printed check with the business name exactly as shown on the IRS form CP575 or a letter from your bank verifying your bank account. The voided check or bank letter must have the business name precisely as on file with the IRS including punctuation, abbreviations, etc. No deviation from the name is allowed by Medicare including corporate suffix such as Inc or LLC, etc. If using a bank letter, it must also include the type of account (checking or savings), the account routing number, the account number, and be signed by a bank representative and written on bank letterhead.

*Required