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Provider Information

First Name

Middle Name

Last Name

Suffix

Professional Title

DOB

NPI

Phone

Format Number as 012-345-6789 or 0123456789

Personal Email

2. Application Request

Specify the preferred BH facilities and specialties

MD Passport PIN

Requested Facility(s)

Select which location(s) you will need privileges for

Indicate your primary facility

Specialty(ies)

Role

3. Practice

Provide current practice details

Practice Name

Office Phone

Format Number as 012-345-6789 or 0123456789

Office Fax

Format Number as 012-345-6789 or 0123456789

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

4. Credentialing Contact (delegate)

Provide your credential contact details Provide your credential contact details

Name

Credentialing Contact Phone

Format Number as 012-345-6789 or 0123456789

5. License

Provide your license details

FL license #

Expiration

6. Board Information

Note: Board eligibility expires 7 years after the completion of your training program for the requested specialty. If not board certified, please provide the date you completed training program

Board Status

If “Not board certified” you will not qualify.

Name of Board

Sub-Specialty Board

DateTrainingProgramCompleted

Expiration/ Eligibility End Date

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Provider Information

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​​​2. Application Request

Specify the preferred BH facilities and specialties

3. Practice

Provide current practice details

4. Credentialing Contact (delegate)

Provide your credential contact details​​ Provide your credential contact details​​

5. License

Provide your license details

6. Board Information

Note: Board eligibility expires 7 years after the completion of your training program for the requested specialty. If not board certified, please provide the date you completed training program

2. Application Request

Provide your credential contact details Provide your credential contact details