List of Documents for Provider Enrollment

  1. Curriculum Vitae
  2. Current state licenses (for all states practicing)
  3. Federal DEA certificate
  4. Current certificate of insurance
  5. Copies of professional diplomas, internship, residency, and fellowship certificates, as applicable
  6. W-9 for each entity the applicant expects will receive payments or reimbursements
  7. Collaborative practice protocols, as applicable
  8. Education Council for Foreign Medical Graduates (ECFMG) certificate
  9. Board certification certificate(s)
  10. Contact information for three (3) professional references
  11. Copy of postgraduate (CME) activities which you attended and for which you have received credit in the past 2 years
  12. United States Military discharge papers/DD214 if discharged from US Military or status if currently serving
  13. CLIA waiver number and identification number (or copy of certificate)
  14. Provide a statement regarding the reasons for any inability to perform the essential functions, with or without reasonable accommodation, for the practice in which you are seeking to become a participating provider.
  15. CPC575 Letter from IRS acknowledging the organization is tied to the appropriate tax identification number