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. Contact Us Today! Patients 866-344-7756 Providers 877-583-2842 Plans 303-407-6812 Get More Info Interpreter Services Winner of a Gold Star Certificate from BBB Denver/Boulder, 2014 HCS is a Sprint CapTel Partner © Hearing Care Solutions 2017, All rights reserved.