Physician Services of Tennessee, LLC

General Application

PERSONAL INFORMATION Credential America _© General Application

Personal Information:

First Name: ________________________ Middle Name: _______________ Last Name: ______________ Suffix: __________

Home Address: ____________________________________________________________________________________________

Home Phone Number: ____________________________ Social Security Number: _________________________________

Degree: MD DO NP PA CRNA PT OT Other: _________________ Date of Birth: ________________

Place of Birth: City ____________ State_______ County __________________ E-Mail: ______________________________

Citizenship: _______________________________ Visa Status (If Applicable): ______________________________________

Marital Status: Married Single Divorced Widowed Spouse Name: __________________________________

Sex: Male Female Race: Caucasian African American Asian Other: ________________

UPIN: __________________ Languages Spoken: ________________ ECFMG: ____________________

OFFICE LOCATION(S)

Office Locations:

Primary Office Location:

DBA Location Name: ________________________________________ Start Date At This Location: ____________________

Address: ______________________________________________________________________________ Suite: ______________

City: _____________________ State: _______ Zip: _________ County: _____________________________________________

Telephone: (____) ____________ Fax: (_____) ____________ Languages Spoken at Office: ________________________

Contact Person:_____________________________ Title: ________________ Telephone: (_____) ____________

Do you provide lab services? In Office Reference Lab Both If In Office, CLIA # ______________________

Is This Your Mailing Address? Yes No Is This Your Billing Address? Yes No

Tax ID: _ Legal Name: _________________

Please tell us about your practice structure:

I am a sole proprietor with payment being made to me as an individual

I am joining an existing group

I am a sole proprietor with payment going to my practice name

I am employed by a hospital

Individual Medicare Number: ___________ Group Medicare Number: ____________Medicaid Number: __________

Age Limitations: __________________________ Handicap Accessible? Yes No

Office Hours: ______________________________________________________________________________________________

Additional Office Location:

DBA Location Name: ________________________________________ Start Date At This Location: ____________________

Address: ______________________________________________________________________________ Suite: ______________

City: _____________________ State: _______ Zip: _________ County: _____________________________________________

Telephone: (____) ____________ Fax: (_____) ____________ Languages Spoken at Office: ________________________

Contact Person:_____________________________ Title: ________________ Telephone: (_____) ____________

Do you provide lab services? In Office Reference Lab Both If In Office, CLIA # ______________________

Is This Your Mailing Address? Yes No Is This Your Billing Address? Yes No

Tax ID: _ Legal Name: _________________

Individual Medicare Number: ___________ Group Medicare Number: ____________Medicaid Number: __________

Age Limitations: __________________________ Handicap Accessible? Yes No

Office Hours: ______________________________________________________________________________________________

BILLING INFORMATION

Billing Information:

Billing Agency Billing In-House

If Agency, Please Give The Following Information:

Name of Agency: _________________________________________________ Tax ID: _________________________________

Date Started Using The Agency: _______________ Contact Person: _______________________ Title: ________________

Telephone: (_____) ____________ Fax: (_____) ____________ E-Mail: _________________________

Please Include A Copy Of Your Billing Agreement With Your Application.

If Billing Is Performed In House, Please Give The Following Information:

Address Where Billing Is Performed: _________________________________________________________________________

Contact Person: _______________________________ Title: ______________________ Telephone: (_____) ______________

Fax: (_____) ____________ E-Mail: ____________________________

Do you have electronic billing capabilities? Yes No What practice management/billing software do you use? ______________________________________

To Whom Should Checks Be Made Payable? _____________________________________________________________

Please Provide Us With The Address For Checks To Be Mailed: ________________________________________________

EDUCATION

Education:

Program: Under Graduate Medical School Internship Residency Fellowship Post Graduate

Institution Name: ___________________________________________________ Degree Obtained: _____________________

Address: ____________________________________ City: ________________ State: _____________ Zip: _________________

Program Director: _________________________________ Type of Program/Specialty: ______________________________

Program Started: ________/________ Program Completed: ________/________ Honors Received: __________________