Provider Credentialing - iPractice Healthcare Business Solutions

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Welcome to iPractice Healthcare Business Solutions. We are a partner with your new medical practice for your insurance enrollment process.

You should have received a checklist of information and documents needed in order to complete this onboarding form.

Please have all information at hand as you will not be able to save this form to complete at a later time.
FOR ALL PROVIDERS: This form is unable to be saved once starting due to firewall issues. Please have the following documentation/information available prior to beginning. -Employment Start Date -Medical License -DEA -NPI info -CAQH login info -CPR Training Certifications (ACLS, BLS, PALS) -Board Certification -Previous liability face sheets -Three Peer References (mailing address, phone number, email address) -CV -Professional Diplomas*

Please initial here that you have read and understood the above requirements. If you are concerned or have issues prior to the beginning please call the office at 512-838-3828 or email julie@rsbcho.com, we are here to help you!
FOR MD/DO AND PEDIATRIC UROLOGY MIDLEVELS: You will need hospital privileges so please select "YES" to that question at the end and have the following additional items available: -Vaccination Record *including COVID-19* -Case log for past 24 months -Professional Photo -Peer references MUST be in the same license designation, midlevel to midlevel and MD/DO to MD/DO – CME for past 24 months (unless you just completed residency or graduated).*
Initial here to acknowledge you understand, you may also list any issues or concerns with the required info above here.
CAQH Account Information- We require your login for the CAQH account, if you do not have one, please complete the Texas Standardized Credentialing Application (TSCA) provided to you and upload into the appropriate file box. If you have one but do NOT know the login or if you need to verify if you DO have one, please visit this site prior to completing the form. https://proview.caqh.org/Login/

Please initial here to verify that you have read and understood the CAQH account information.
Start Date*
MM slash DD slash YYYY
Name*
First Middle Last
Previous names & dates used
License Type*
Practice Name*
Supervising Physician
For mid-levels only
First Last

Demographic Information
Your DOB*
Personal Email*
Work Email
Personal Phone*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Peer Reference #1 Name*

We need 3 peer references that hold the same level of licenses.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Peer Reference #2*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Peer Reference #3*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*

Medical License(s)*
Please upload all your licenses even those from previous states: (color copy preferred) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 10.
DEA and CDS (where applicable)
Please upload your documents: (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Current Practice/Employer Name
End Date (MM/DD/YYYY)

Please provide your end date with current employer or planned exit date. Please type N/A if not applicable.
CV / Resume
Please upload your resume: (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Copy of Highest Degree Earned*
Please upload a copy of your Masters, Medical Degree, or Ph.D. allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Copy of your ID*
Please upload a color-copy of your Driver’s License, State ID or Passport: (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Copy of your CPR Training Certifications (ACLS, BLS, PALS)
Please upload a color-copy of your certifications (IE PALS, BLS, CPR, CLIA) (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Copy of your CPR Training Certifications (ACLS, BLS, PALS)
Please upload a color-copy of your certifications (IE PALS, BLS, CPR, CLIA) (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Copy of NPI letter of registration or NPI Registry profile
Please upload a color-copy of your NPI letter of registration (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Board Certification
Please upload a color-copy of your Board Certification (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.

List hospitals where you currently have privileges.
Do you require hospital privileges?
- No
- Yes
Case Logs past 24 months
Please upload Case Logs past 24 months, NO PATIENT INFORMATION just date of service and CPT code billed. (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Vaccination Record *For Hospital Providers ONLY*
Please upload Vaccination Record that includes HepB series completion, Flu, TB and COVID-19 (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Professional Photo *For Hospital Providers ONLY*
Please upload your photos (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
CME past 24 months *For Hospital Providers ONLY*
Please upload CME past 24 months (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Residency Training Letters for Advanced Surgical Privileges *For Hospital Providers ONLY*
Please upload Residency Training Letters for Advanced Surgical Privileges (color copy) allowed file types: doc, docx, pdf, jpg, png, bmp, gif
Drop files here or

Accepted file types: pdf, jpg, png, docx, bmp, gif, doc, docx, Max. file size: 32 MB, Max. files: 6.
Upload other documents here.
File
Max. file size: 50 MB.
File
Max. file size: 50 MB.
File
Max. file size: 50 MB.
File
Max. file size: 50 MB.
File
Max. file size: 50 MB.