Physician Information Form Healthcare Advocates, Inc. 1420 Walnut St., Suite 908 Philadelphia, PA 19102 Tel (215) 735-7711 Fax (215) 735-7737
Provider's name:
Phone #:
Address:
Specialty(s):
State(s) in which you are licensed to practice:
Hospitals at which you have admitting privileges:
What medical school did you attend:
Where did you complete your residency:
Did you complete a fellowship or advanced training? Where?: How many years have you been in practice:
Are you board certified: yes no n/a
Is your medical license in good standing: yes no
Do you agree to inform Healthcare Advocates of any sanctions placed against your license for the sole purpose of removing your name from our referral list: yes no
What insurance plans do you accept:
Do you accept Medicare assignment as payment in full: yes no depends on situation
Describe your practice style, unique qualifications or comments on the back of this form: