Thank you for your interest in joining the Provider Panel. Please fill out the application below.

Licensed Independent Practitioners Application

Demographic Information (and directory information)

National Databank Identifying Information (required for data bank queries)

Services you wish to provide*

Payment Information

Current Professional Liability Insurance Information

Insurance #1

Add Insurance

Valid Certifications/Licenses*

Indicate all past and current licenses and certifications. Physicians – include Board Certifications

Add Certificate/License

Education

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.

Professional Experience

You MUST attach current CV/Resume with full details of a minimum 5 years professional experience MUST BE IN “MM/YY” format

Employer #1 (Most Recent)

Add Experience

Professional References

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.

Reference #1

Reference #2

Reference #3