Onboarding – US Healthcare Licensing

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Provider Onboarding

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Provider Onboarding - Step 1 of 6

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to the Address

First Name *

Middle Name

Leave blank if no Middle Name

Last Name *

Degree *

Home Address *

Address Line 1

City

State

Zip Code

Biz Address

Address Line 1

City

State

Zip Code

Cell Phone *

Personal Email *

Home Phone

Work Email

Business Phone

Prefered method of contact

Email
Phone

Parent Names

Many State Medical Boards ask for Parent Names

Father's First Name

Mother's First Name

Father's Middle Name

Mother's Middle Name

Father's Last Name

Mother's Maiden Name

Fingerprinting Information

Date of Birth *

Height *

Social Security Number

Weight *

Sex *

Hair *

Ethnicity *

Eyes *

Place of Birth

City *

State/Region/Province *

Region/Province

Country *

Country of Citizenship *

Foreign med school graduate?

No, US Graduate
Yes

ECFMG #

Issuance Date

Military Service

Military Service *

Yes, I served
No
Military Spouse

Branch

Entry Date

Exit Date

Discharge Type

DEA License Information

Please indicate all licenses Current or Expired

# of DEA License's *

0
1
2
3

DEA Number *

Expiration Date

Registration Facility

Registration Address

Address Line 1

City

State

Zip Code

DEA Number #2

Expiration Date

Registration Facility

Registration Address #2

Address Line 1

City

State

Zip Code

DEA Number #3

Expiration Date

Registration Facility

Registration Address #3

Address Line 1

City

State

Zip Code

Personal References

Select state if acquiring license:

GA
NC
NH
OR
VT
WY

These states require references. NEXT if not applicable.

Full Name w/Degree

Phone

Email

Years known

Address

Address Line 1

City

State

Zip Code

Full Name w/Degree

Phone

Email

Years known

Address

Address Line 1

City

State

Zip Code

Full Name w/Degree

Phone

Email

Years known

Address

Address Line 1

City

State

Zip Code

Practice History Questions

Have you ever been subject to any of the following (when in doubt, DISCLOSE)

Any incidents including arrests and malpractice, even if dropped, that are not reported on this questionnaire will be subject to additional billable time during licensure. Our process of discovery is necessarily very thorough.

Please be honest when answering the questions.

Undergraduate, graduate, postgraduate action/extensions/leaves of absence? *

Yes
No

(including maternity leave/illness/any period of time where you were absent)

Malpractice claims and cases, regardless of the outcome? *

Yes
No

Arrests/charges/convictions? *

Yes
No

(including dropped/expunged/sealed records)

Medical license application withdrawals/denials? *

Yes
No

(whether voluntary, involuntary, or no longer pursuing that license)

Medical license, DEA, Controlled substance registration investigation/action? *

Yes
No

Hospital privilege investigation/action, or voluntary/involuntary resignation in lieu of investigation/action? *

Yes
No

Medicaid/Medicare/third-party payor action? *

Yes
No

Reported to the NPDB for any reason? *

Yes
No

Exam failures? *

Yes
No

If you've answered yes to any of the above questions, please provide a short explanation of the events that took place:

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Info@USHealthcareLicensing.com

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Fleming Island, Florida 32006

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