Application - please print out and fax to us.
| Doctor’s Name: | NPI# | |
| Title: | MD DO DC DPM Other: | |
| Directory Specialty: | ||
| Address: | ||
| City: | ||
| State: |
Zip Code:
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| Federal Tax ID #: | NPI #: | |
| Phone: |
Fax:
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| Email: | ||
*Please submit secondary locations on a separate sheet
Credentials
| Malpractice Insurance Carrier: |
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| Name: |
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| Expiration Date: |
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| State License | ||
| Number: |
Expiration Date:
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| DEA Certificate* | ||
| Number: |
Expiration Date:
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*Does not apply to D.C. Enclose copy of Malpractice License and DEA
(Submit copy of Malpractice, License, and DEA Certificate)
Professional and Personal Information
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1. Has your license ever been revoked, suspended,or limited in any way in any jurisdiction?
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Yes No | |
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2. Have you ever been convicted of a felony?
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Yes No | |
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3. Are there any past or current pending legal actions or decisions against you or your practice? If yes, please explain on a separate sheet.
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Yes No | |
Payment Information
| I am submitting my $95 membership fee by: | Check Visa/MasterCard American Express | |
| Card Number: |
Expiration Date:
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I authorize the above card to be charged for my membership fee.
Signature: _____________________________________ Date: __________________________
I represent that I have read and understand this document. I further represent that all of the information submitted on the above enrollment form is correct to the best of my knowledge.
Signature: _____________________________________ Date: __________________________
Fax to secure fax line 602-485-3100
Or mail to 3420 E. Shea Blvd, 130 Phoenix, AZ 85028