Get Physician Data Sheet

Filling out the Physician Data Sheet online is essential for initiating the credentialing process for therapists at your clinic. This guide will walk you through each section of the form, ensuring you provide all necessary information accurately.

Follow the steps to complete the Physician Data Sheet online.

1. Click ‘Get Form’ button to access the Physician Data Sheet and open it in your preferred digital document editor.
2. Begin by entering your last name, first name, and middle initial in the designated fields. If applicable, include your former last name as well.
3. Indicate your provider type by selecting the appropriate checkbox: DC, PT, OT, SLP, LAC, MT, or ND.
4. Fill out your Social Security number and date of birth in the specified sections.
5. If necessary, indicate whether you have a Medicaid/TPIN number and enter your NPI and Medicare numbers if applicable.
6. Provide your tax ID, if applicable, and indicate whether you have a CAQH ID.
7. Enter the clinic name, street address, suite number, city, state, phone number, fax number, and zip code in the appropriate fields.
8. Complete the mailing address section with suite number, city, state, and zip code.
9. Fill in the credentialing contact's name, phone number, and email for communication purposes.
10. Provide your state license number and confirm if you are registered with CAQH.
11. After filling out all the fields, review your information for accuracy. Save any changes you made.
12. Download, print, or share the completed Physician Data Sheet as required to submit it.

Ready to begin? Complete your documents online today!