Physician Credentialing Order Form

Full name *

Email address *

Phone number *

Mailing Address: Street, City, State, Zip Code *

Degree Type: MD, DO, etc. *

Place of Birth: *

Date of Birth: *

Social Security Number *

Do you want to designate another person to be our Credentialing Contact for you? *

Yes

If "yes", Name of Contact Person:

Email of Contact Person:

Phone Number of Contact Person:

Is your CAQH File Active? *

Yes

CAQH Username: *

CAQH Password: *

Credit Card Number *

Credit Card Expiration Date *

3-4 Digit Code *

Name on Credit Card *

Complete Billing Address *

I authorize MedLicense.com to charge my credit card $499 for annual Credentialing Services. I understand that the service will be renewed on an annual basis until I request that the service be stopped. I understand that the service fee is non-refundable. *

I agree