With your HNA Membership you also receive a free subscription to
Practice HQ.com!

Disclaimer

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:
Federal Tax ID #:	NPI #:

Phone:	Fax:
Email:

*Please submit secondary locations on a separate sheet

Credentials

Malpractice Insurance Carrier:
Name:
Expiration Date:
State License
Number:	Expiration Date:
DEA Certificate*
Number:	Expiration Date:

*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

1. Has your license ever been revoked, suspended,or limited in any way in any jurisdiction?		Yes No
2. Have you ever been convicted of a felony?		Yes No
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.		Yes No

Payment Information

I am submitting my $95 membership fee by:	Check Visa/MasterCard American Express
Card Number:	Expiration Date:

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

3420 E. Shea Boulevard | Suite 130 | Phoenix, AZ 85028 | Phone 877-311-3338 | Fax 602-485-3100

With your HNA Membership you also receive a free subscription to Practice HQ.com!

With your HNA Membership you also receive a free subscription to
Practice HQ.com!