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Completed Request for Taxpayer
Identification Number and Certification form |
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Copy of valid state license |
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Copy of DEA registration certificate |
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Copy of CDS certificate (if applicable) |
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Copy of Board certificate if not certified
copies of internship and residency, and/or fellowship certificates |
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Copy of malpractice insurance $1,000,000,
$3,000,000 or state requirements |
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List of active hospital privileges |
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List of pending/paid claims within last
five years |
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Copy of curriculum vitae noting explanations
of any gaps in work history |
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