Apply to Become a Physician Affiliate Provider Credentialing Application Cirrus Medical Network Physician Affiliate Application Are you a physician based and licensed in the United States?*Cirrus Medical Network is currently only hiring U.S. based and licensed physicians. Yes No Sorry. What would you like to do next?Unfortunately, you do not qualify to work as a Cirrus Medical Network provider at this time. Disregard my inquiry. Contact me now to discuss further. Put me on the list to be contacted if CirrusMED expands the network. Today's Date* MM slash DD slash YYYY Provider Name* First Last Degree(s)*MDDOPhDMPHMBAOther MastersAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone - Cell/Mobile*Phone - Home/OtherList an alternative phone if available.Email - Preferred* Enter Email Confirm Email Email - SecondaryEnter your secondary email, to be used as a back-up only. Enter Email Confirm Email Gender*MaleFemalePrefer Not to AnswerDate of Birth* MM slash DD slash YYYY Language*EnglishSpanishOtherDo you have an NPI Number?* Yes No Not Sure NPI# Do you have a DEA Number?* Yes No DEA NumberWhat is your DEA Number? Medical School* Year of Graduation - Medical School What is your specialty?* Family Medicine Internal Medicine Pediatrics Med/Peds General Practitioner Psychiatry Residency/Internship*Enter your Residency details. Example: Mayo Clinic, 1996-1999, Family Medicine. Include internship information if applicable. Additional Training/Expertise?State(s) Of Medical Licensure*Please select the States where you are licensed to practice medicine. Hold the CTRL button to multi-select.AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBoard-Certified?* Yes, I am Board-Certified No, I am NOT Board-Certified No, but I AM Board-Eligible Board CertificationPlease list your Board-Certifying Agency (e.g. American Board of Family Medicine) Year of Board-Certification?List year of last Board-Certification or Re-Certification (e.g. 2016) Are you currently employed? Yes No Medicare participatory status? Opted IN Opted OUT Not Applicable Are enrolled/participatory (opted-in) in Medicare or opted-out? EmploymentEnter your current employment information here. Example: XYZ Medical Group, Anywhere, USA - 2003- presentEmployment HistoryEnter your past employment information here. Example: XYZ Medical Group, Anywhere, Anystate - 2003- 2006, ABC Hospital, Anywhere, Anystate, 2006-2009, etc. You may also specify--> see CV. Additional InformationPlease add any additional information that you feel would be important for either Cirrus Medical Network, or prospective patients to know about you. Areas of interest, hobbies, etc.File UploadsFor verification purposes, please upload copies of your medical credentials below using one of the following formats: jpg, png, gif or PDF. These may be uploaded in the future if you do not have them available at this time. Copy of CVUpload of copy of your Curriculum Vitae (CV) or Resume. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB. Copy of Medical School DiplomaUpload a copy of your medical school diploma (DO, MD, etc.) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB. Copy of Residency DiplomaUpload a copy of your Residency Diploma here. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. Copy of State Pharmacy Certificate Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB. Upload a Copy of your State Pharmacy Certificate(s)Copy of State Medical License(s)Upload a copy of your State Medical License(s) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB. Your PhotoPlease upload a professional-appearing photo/headshot of yourself. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. I attest that all of the above information is true and correct.* YES NO PhoneThis field is for validation purposes and should be left unchanged. Δ
