Provider Intake Form | Circle Solutions

Personal Information:

Layout

First Name: *

Last Name: *

Birth Date: *

Rendering NPI (Type 1) *

Gender: *

Social Security Number (SSN): *

Race/Ethnicity:

Personal Contact Information:

Layout

Phone *

Email *

Mailing Adress:

Please provide a reliable address where you can receive physical mail. Ideally this is a location where you will continue to receive mail in the event that your practice location were to change.

Mailing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Practice Information:

Practice Name: *

Practice Location: *

Address Line 1

Address Line 2

City

State

Zip Code

Practice Liability Insurance:

Click or drag files to this area to upload. You can upload up to 5 files.

All behavioral health providers are required to maintain liability insurance in order to bill & collect from most insurance panels. Minimum coverage amounts are $1,000,000/ per occurrence & 3,000,000 / Aggregate

Licensure & Résumé

Please upload a copy of your professional license(s) and résumé below:

Professional License: *

Click or drag files to this area to upload. You can upload up to 5 files.

Professional Résumé *

Click or drag files to this area to upload. You can upload up to 5 files.

Certifications & Specialties:

Please describe any certifications and/or specialties you may have below:

Are you Board Certified? *

Board certification requirements go above and beyond state licensing requirements. The “Board Certified” title recognizes providers that acquired certification to demonstrate an expertise in a particular specialty. This certification process is voluntary and not to be confused with the examinations taken to meet the requirements needed to apply for a license to practice in your state

Certifications:

Specialties:

Disclosures:

Have your licenses, clinical privileges, certifications, etc. ever been adversely effected? *

Select 'Yes" if any of these have ever been relinquished, denied, revoked, sanctioned, challenged, investigated, surrendered, etc.

Has your professional liability policy ever been adversely effected? *

Select 'Yes" if your liability policy has ever been cancelled, restricted, declined, had a claim submitted, etc.

Have you ever been convicted of or plead guilty to a crime? *

Excluding any minor traffic violations, select 'Yes' if you have ever been convicted/plead guilty to a felony, misdemeanor, civil offense, etc.