Thank you for your interest in joining the Provider Panel. Please fill out the application below.
Indicate all past and current licenses and certifications. Physicians – include Board Certifications
You must provide an original transcript for your highest degree – this must be sent directly to MSHN from the conferring institution and not delivered by the applicant.
You MUST attach current CV/Resume with full details of a minimum 5 years professional experience MUST BE IN “MM/YY” format
Please provide the names and addresses of three (3) individuals and/or organizations who can verify your employment over the last five (5) years and can comment on your scope/level of performance, clinical performance, satisfactory professional obligations, ethical performance, clinical judgement, and technical skills in performing procedures and in treating and managing client’s needs.
The first reference must be your most recent employer/organization.