MedLicense.com, Helping Physicians with Licensure.

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Insurance Credentialing

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To Begin the process please enter your information below:

Please list all Insurance Plans which you desire to credential with:
Are you adding yourself to an existing group? Yes No If yes then enter the Group Name: If no do you need to credential your Group/Practice? Yes No
Type of License (i.e. - MD, DO, MD/PHD, NP, PA, etc.)	Male Female USA Citizen? Yes No

Full Legal Name

Contact Phone Number

Maiden Name

Work Phone Number

US Social Security Number

Fax Number

Mailing Address

Email Address

Employer Name/ Group Name:

Work Address:

List all States where you have held a State Medical License:

Date of Birth Place of Birth

Board Certification: Yes No ABMS Specialty (Board Certification) Initial Certification Date, Re-certification Date

Degree: MD DO MD/PhD MBBS

Exact Date of Graduation: (MM/DD/YY) //

Are there any "negative" issues which need to be discussed including; Board Actions,

Arrests, Leave of Absences, Withdrawals, Malpractice, Etc. which will need to

be disclosed?

Yes No

Credit Card Information

Credit Card First Name: Credit Card Last Name:

Billing Address: Phone Number:

Card Number: Exp. Date: 3 Digit/4 Digit Security Code

How did you hear about us?

Immunity and Release I hereby extend absolute immunity to, and release, discharge and hold harmless from any and all liability Medical Administrators of America L.L.C. d.b.a. MedLicense.com, its agents, representatives, directors, members, and officers; for any acts, communications, reports, records, transcripts, statements, documents, recommendations or disclosures involving me, made in good faith and without malice, requested or received by Medical Administrators of America L.L.C. dba MedLicense.com. I further hold blameless Medical Administrators of America L.L.C. dba MedLicense.com for the actions of any third party which is required in the involvement of the licensure process as mandated by state medical board regulation. I understand that Medical Administrators of America L.L.C. d.b.a. MedLicense.com does not make any representation as to the period of time which it will take for the state medical board to issue my medical license. I also acknowledge that Medical Administrators of America L.L.C. does not issue medical licenses nor provide legal advice concerning the medical licensure process. Medical Administrators of America L.L.C. d.b.a. MedLicense.com provides administrative services in the preparation of state medical board applications and forms. By hitting the submit button below, I acknowledge and agree with the above statement.

Agree to terms of release

Would you like to add Medicare/Medicaid Registration Services for $1200.00? Yes No	Yes
Add License / Permit Auto-Renewal Services for $170.00 ($170.00 per license/permit - per renewal period) Yes No	Yes
Would you like to add DEA Registration Services for $120.00? (Regular price is $190.00) Yes No
Would you like to add Document Storage Services for $295.00? (Regular price is $415.00) Yes No

Please press the submit button to submit your order:

Important! Please Fax or Email your CV'/ Resume' to us after you hit the Submit Button.

Fax # 770-217-9937 Email: info@medlicense.com

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