AllStar Billing Service - Credentialing

Personal Information

Last Name *

First Name *

Middle Initial

Email *

Date of Birth *

SSN *

Upload CV/Resume

Accepted formats: PDF, DOC, DOCX

Education Information

Medical School/College

Graduation Date

Upload Degree/CV

PDF, JPG, JPEG, or PNG (Max 10MB)

Professional License

License Number *

State *

Issue Date

Expiration Date *

Has your license ever been revoked and/or suspended?

Upload Professional License

PDF, JPG, JPEG, or PNG (Max 10MB)

DEA License

DEA Number

State

Issuance Date

Expiration Date

Upload Professional License

PDF, JPG, JPEG, or PNG (Max 10MB)

Board Certifications

Board Name

Certification Number

Issue Date

Expiration Date

Upload Board Certification

PDF, JPG, JPEG, or PNG (Max 10MB)

NPI Information

Individual NPI *

Individual Taxonomy Code

Group Information

Group NPI *

Group Taxonomy Code

Group Name *

Tax ID (TIN) *

Phone Number

Fax Number

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Upload W-9 Form

PDF, JPG, JPEG, or PNG (Max 10MB)

CLIA Waiver Information

CLIA Waiver Number

CLIA Waiver Effective Date

CLIA Waiver Expiration Date

Upload CLIA Waiver

PDF, JPG, JPEG, or PNG (Max 10MB)

Banking Information

Bank Name

Routing Number

Account Number

Upload Voided Check

PDF, JPG, JPEG, or PNG (Max 10MB)

Malpractice Insurance

Insurance Company

Policy Number

Policy Start Date

Policy End Date

Coverage Amount

Upload Malpractice Insurance Certificate

PDF, JPG, JPEG, or PNG (Max 10MB)

CAQH Information

CAQH Number

CAQH Username

CAQH Password

Credentialing Intake Form

Personal Information

Education Information

Professional License

DEA License

Board Certifications

NPI Information

Group Information

CLIA Waiver Information

Banking Information

Malpractice Insurance

CAQH Information

Miscellaneous Information