Provider Application

This is the full Provider Application. To add a new provider to your office, please click here: Add a new Provider to your office.

If would like to have a printable version, please click here: HCS – Provider Application 2017

Provider Application


Provider Information - Section 1


Please fill in all of the fields. Do not close the window, otherwise your progress will be lost. This application will have THREE sections and an 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. If you would like the printable application please click the above link.


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 Certification Yes No
 
Board Expiration Date
AHSA CCC-A Yes No
 
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



Have you ever been asked to resign or been terminated from any of the positions above?
 Yes (if yes, please provide an explanation below) No



Termination Reason

Please attach any additional work history
 
Upload


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 School Associates Bachelors Masters Doctorate
 
Graduation Date

I, the undersigned, understand that by not providing a copy of my degree / diploma with the HCS provider application, I am verbally verifying my degree is valid and that Hearing Care Solutions, Inc. may use this information for any credentialing needs. I attest this information is true and accurate to the best of my knowledge.

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




Check here if you accept these terms.