Provider Data Collection Sheet

The MarketingPros

Provider Data Collection Sheet
CONFIDENTIAL — For credentialing use only
Version 1.0

Complete all fields before submitting any credentialing applications. Missing data = application delays.

Instructions for practice managers: Send this form to each new provider on their first day. Collect the completed form along with physical copies of all documents listed in Section 7 before beginning any credentialing application. Fields marked * are required for every application.

1 — Personal & Professional Information

Legal Last Name

Legal First Name

Middle Name / Initial

Preferred Name / Goes By

Credentials / Degree

Date of Birth

Social Security Number (last 4)

Full SSN collected separately via secure intake — document this form only shows last 4

Gender (as listed on professional license)

Home Address

Personal Cell Phone

Personal Email (for payer correspondence)

Languages Spoken

2 — Licensure & NPI

Individual NPI (Type 1)

Verify at npiregistry.cms.hhs.gov

Primary State of Licensure

Medical License Number

License Issue Date

License Expiration Date

Additional State Licenses (if applicable)

State

License Number

Expiration Date

State

License Number

Expiration Date

DEA Certificate Number

DEA Issue Date

DEA Expiration Date

DEA State(s) / Address on Certificate

CAQH ProView ID (if existing)

CAQH Last Attestation Date

Must be within 120 days — re-attest if expired

3 — Education & Training

Medical School Name

Medical School Location (City, State, Country)

Medical School Graduation Date

Degree Awarded

Internship

Institution

Start Date

End Date

Residency

Institution

Specialty

Start / End Date

Fellowship (if applicable)

Institution

Specialty

Start / End Date

Board Certification(s)

Certifying Board

Certification Date

Expiration Date (if time-limited)

4 — Malpractice Insurance

Current Malpractice Carrier

Policy Number

Coverage Per Occurrence

Aggregate Coverage

Policy Expiration Date

Prior carrier(s) — last 5 years (carrier name, policy #, dates)

Have there been any malpractice claims, settlements, or judgments in the past 10 years?

No Yes — provide details below

5 — Hospital Affiliations & Privileges

Hospital Name

Privilege Type

Since (Date)

Hospital Name

Privilege Type

Since (Date)

Have hospital privileges ever been denied, restricted, suspended, or revoked?

No Yes — provide details

6 — Work History (last 5 years)

Employer / Practice Name

Start / End Date

Employer / Practice Name

Start / End Date

Explain any gaps in employment (> 30 days)

7 — Document Collection Checklist

Check each box once the document has been received and verified. Do not begin applications until all critical documents are in hand.

✅ Medical license (current, unrestricted) ✅ DEA certificate (if applicable) ✅ NPI confirmation letter / NPPES printout ✅ Malpractice certificate of insurance ✅ Board certification certificate(s) ✅ Medical school diploma ✅ Internship / residency completion letter ✅ Fellowship completion letter (if applicable) ✅ Current CV (updated within last 6 months) ✅ Government-issued photo ID ✅ W-9 (for billing setup) ✅ Signed HIPAA business associate agreement

8 — Provider Certification & Signature

I certify that all information provided on this form is accurate and complete to the best of my knowledge. I understand that omissions or misrepresentations may result in credentialing denial or termination. I authorize [Practice Name] and its affiliated practices to submit this information to payers and credentialing organizations on my behalf.

Provider Signature

Date

Printed Name