Get Practitioner Request For A Military Onesource Application

The Practitioner Request For A Military OneSource Application is a vital document for practitioners seeking to become contracted providers. This guide offers clear and step-by-step instructions to help users navigate the online form effectively.

Follow the steps to complete your application seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your name clearly in the designated area. Ensure that you print all information accurately.
3. Indicate your licensure type and complete your work address details, including city, state, zip code, and county.
4. Provide your work phone number, including the area code, followed by your work fax number with the area code.
5. Enter your email address for communication, and then fill in your birth date using the format MM/DD/YY.
6. Input your social security number, DEA number, and controlled dangerous substance (CDS) number.
7. If applicable, indicate your board certification status. If you are a non-MD, confirm your experience level by answering whether you have three years of experience post-licensure at the highest level of independent practice.
8. For MDs only, indicate whether you completed a three-year residency in psychiatry.
9. Confirm whether your graduate school or residency program is accredited.
10. State if you are a Medicare participating provider.
11. After completing the form, ensure all information is correct, then save your changes. You can download, print, or share the form as needed.

Start filling out your Practitioner Request For A Military OneSource Application online today!