Please fill in all of the fields. Do not close the window, otherwise your progress will be lost. Following this section will be the agreement section. Each section must be submitted before continuing to the next. As soon as you submit one section you will not be able to go back.


Provider Added For:


Location Name: (Required)
DBA Name (if different than above)
Address (required)
 
Suite
City (required)
 
State (required)
 
Zip (required)

Do you have multiple locations?
YesNo
Additional locations (please provide the address, hours of operation, and phone)


Provider Details


Provider Name (Required)

Professional Title (required)
 
NPI Number (required)
Provider Phone (required)
 
Social Security Number (required)
Provider Email (required)
 
Date of Birth (required)


Professional Credentials


Professional Affiliations

Audiologist License #
 
Hearing Aid Dispensing #
Board CertificationYesNo
 
Board Expiration Date
AHSA CCC-AYesNo
 
ASHA Expiration Date
Medicade # (if applicable)
 
Medicare # (if applicable)


Work History

(Please provide work history for the past 6 years, any gaps exceeding 6 months provide an explanation. If you require additional space, please fill in the first two and attach additional documentation below by clicking on the "UPLOAD" button.)



Place of Employment

From
 
To
 
Title

Responsibilities

Place of Employment

From
 
To
 
Title

Responsibilities



Upload Supporting Documents



Please upload your supporting documents including:

  • license
  • insurance
  • diploma (if applicable)
  • W-9
  •  

    (file-size limit is 2MB)


     


    Have you ever been asked to resign or been terminated from any of the positions above?
    NoYes (if yes, please provide an explanation below)



    Termination Reason


    Education

    To be filled out if you omit a copy of your degree/diploma. If you have a copy of your diploma, please upload it at the end of this form (in the submission checklist section)



    Name of School

    Highest Level of Education
    High SchoolAssociatesBachelorsMastersDoctorate
     
    Graduation Date


    Compliance Checklist

    1. Has your license to practice in any jurisdiction ever been limited, suspended, or revoked?
    YesNo
    2. Have you ever been denied membership or renewal therof or been subject to disciplinary action in any medical organization?
    YesNo
    3. Are you currently having any medical and/or physical problem(s) which would adversely affect your ability to practice?
    YesNo
    4. Do you have any chronic illness and/or communicable infectious disease that may be a potential danger to patients?
    YesNo
    5. Are you or have you been involved in a malpractice suit?
    YesNo
    6. Has any malpractice carrier ever made an out-of-court settlement or paid a judgment on a professional liability claim on your behalf?
    YesNo
    7. Has your malpractice coverage ever been denied or cancelled?
    YesNo
    8. Are you currently under indictment for any crime?
    YesNo
    9. Have you ever been convicted of or pleaded no contendere to a felony or other criminal offense, including, without limitation, a criminal offense related to Medicare, Medicaid, or any other federal program?
    YesNo
    10. Have you ever been expelled, excluded, or suspended from any federal program of from service reimbursement under Medicare or Medicaid?
    YesNo
    11. Do you have a history of chemical dependency/substance abuse or currently abuse drugs/alcohol?
    YesNo

    If you answered YES to any of the above questions, please include an explanation below.



    I attest this information is true and accurate to the best of my knowledge and that Hearing Care Solutions, Inc. may use this information for any credentialing needs.

    Print Full Name (Required)
    Please sign below (with your mouse)

    Electronically Sign Below (with your mouse) (Required)


    Please send updated copies of your W9, Liability Insurance and Licensure to applications@hearingcaresolutions.com. Failure to send these documents will result in delays in the recredentialing process.