1. Answer All questions on the application
2. Signed Attestation
3. CV (résumé)
4. Copy of license- all states in which practitioner is actively seeing patients
5. Copy of DEA (if applicable) – DEA must reflect the current state practitioner is seeing patients
6. Copy of controlled substance, if applicable
7. Copy of board certification (if applicable)
8. On application, list hospital affiliation (s) or hospital arrangements (name of a provider that will admit patients on the practitioner’s behalf.
9. 3 References
10. Proof of liability
11. NPI Number
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