Provider Application Form 1

Name & Title

First Name *

Last Name *

Job Title *

Phone

Cell Phone for Text / SMS *

Landline Phone No.

Extension if any

Email

Email *

Communication Preferred *

Text

Email

Call

License in Texas

Have Full unrestricted medical license in TEXAS ? (NOT limited license) *

Yes

No, Please stop here. Do not proceed. We need it for our contractors.

Insurance

Have malpractice insurance or professional liability insurance ?

Yes

No, but I'm ready to get it ASAP.

No, I’m Not ready to get it. Please stop here. Do not proceed. We need it for our contractors.

E-Prescribing

Have E-Prescribing system HIPPA Compliant ? *

Yes

No, but I'm ready to get it ASAP.

No, I’m Not ready to get it. Please stop here. Do not proceed. We need it for our contractors.

Audio, Video, Message, Sharing file

Have an calls, messaging, video chat, & secure file sharing Systetm HIPPA Compliant? *

Yes

No, but I'm ready to get it ASAP.

No, I’m Not ready to get it. Please stop here. Do not proceed. We need it for our contractors.

Fax or eFAx

Have Fax or eFAX ? *

Yes

No, but I'm ready to get it ASAP.

No, I’m Not ready to get it. Please stop here. Do not proceed. We need it for our contractors.

Comments

Any comments for us ?