Secure Order Form

Insurance Credentialing

        MedLicense   Telemedicinelicense   Telepathologylicense   Teleradiologylicense

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                            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                                   


        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?  

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: is a subsidiary of Medical Administrators of America L.L.C.