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HOME ► Physician Reviewer Profile

Physician Reviewer Profile

Please fill in as much information as possible, including all required fields, and then click "Submit" at the bottom of this page when you are finished.

*Denotes required field
First Name:*
Last Name:*
License #:
UPIN #:
State(s) of Licensure:
 
Group Name (if any):
 
Primary Office Address
Street:*
City:*
State:*
Zip:*
Office Phone:*      Fax:  
Office Contact Name:
E-mail Address:
 
Regular Office Hours and Days:
 
Day(s) Available
Please check all that apply
    Click here to select every day 		Monday Tuesday Wednesday
Thursday Friday Saturday
Sunday
 
Will you review cases through our Internet-based system? Yes     No
 
Are you currently actively treating Medicare patients (a minimum of 20 hrs/week)? Yes     No
 
Primary Specialty:*
 
Secondary Specialty:
 
Associates/Physicians You Share Call With:
 
Board Certifications:
 
Board Eligibility:
Nevada State Medical Association Member:
Yes    No

Utah Medical Association Member:
Yes    No		 County Medical Society Member:
Yes    No
 
Hospitals where you have admitting priviledges (#1 is primary):
1. 4.
2. 5.
3. 6.
 
HMO/PPO Affliations:
1. 4.
2. 5.
3. 6.


By submitting this form, I acknowledge that all information provided to HealthInsight for enrollment and participation on the Physician Reviewer Panel is true and accurate.

Thank You For Your Participation!
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