Please list all the states in which you are licensed in:

Section 2: Licensing

Medical License Number(s)

If licensed in multiple states, separate with commas (e.g. CA: A12345, NY: 98765)

DEA Schedules Authorized

I attest my CAQH profile is current within the last 90 days

Confirmed.

Malpractice Policy Number

Malpractice Expiration Date

Please upload your state medical license(s)

Please upload all files as PDF. If needed, you can use free file converter here.

Please upload your DEA Cert

Please upload all files as PDF. If needed, you can use free file converter here.

Please upload your CV

Please upload all files as PDF. If needed, you can use free file converter here.

Last 10 years of practice.

Please upload your Government-Issued photo ID.

Driver's license or passport

Please upload all files as PDF. If needed, you can use free file converter here.

Please upload your malpractice declarations page.

Please upload all files as PDF. If needed, you can use free file converter here.

Hours available per week:

Earliest date you can start seeing patients:

Section 3: Credentialing & Digital

Which Insurance Payers are you currently credentialed with under your individual NPI?

List any payers not in the above list, or note state specific BCBS/Medicaid Plans.

Click Below:

I authorize Same-Day Psych to verify my credentialing status with each payer above and to initiate group credentialing on my behalf with our PC

I do not authorize Same-Day Psych to verify my credentialing status with each payer above and to initiate group credentialing on my behalf with our PC

Zocdoc profile URL (if you have one)

Please put N/A if you do not have one.

I want Same-Day Psych to manage my Zocdoc profile (create or take over existing.

Yes, please.

Psychology Today profile URL (if you have one)

Please put N/A if you do not have one.

I want Same-Day Psych to manage my Psychology Today profile

Yes, please.

Personal practice URL (if you have one)

Please put N/A if you do not have one.

Google Business profile URL (if you have one)

Please put N/A if you do not have one.

LinkedIn URL (if you have one)

Please put N/A if you do not have one.

Click below:

I authorize Same-Day Psych to optimize and manage my listed online profiles, including responding to patient reviews on my behalf per agreed standards

EPCS (Electronic Prescribing of Controlled Substances) Status

Currently enrolled and active

Enrolled but inactive

Board Certification(s)

Please upload Board Certification(s)

Please upload all files as PDF. If needed, you can use free file converter here.

Comfort level with prescribing controlled substances

Comfortable with all schedules I'm authorized for

Limited (e.g. won't prescribe stimulants)

Won't prescribe controls in this practice

Want to discuss case-by-case

Any prescribing limitations we should know about

Maximum patient panel size you'd be comfortable carrying

Total active patients across all visit types

Do you currently have an existing patient panel from another practice?

Yes, would like to bring them over.

Yes, but not bringing them.

Please confirm by clicking the box below:

I attest that all information provided on this form is true and accurate to the best of my knowledge. I understand that misrepresentation may result in denial or termination of my contract.

Same Day Psych - Provider Application

Section 1: Basics

Full legal name

Preferred Name (Optional)

What is your email address?

What is your phone number?

Please list all the states in which you are licensed in:

Specialty

Section 2: Licensing

Medical License Number(s)

DEA Number

DEA Schedules Authorized

NPI Number

CAQH ID

I attest my CAQH profile is current within the last 90 days

Malpractice Carrier

Malpractice Policy Number

Malpractice Expiration Date

Please upload your state medical license(s)

Please upload your DEA Cert

Please upload your CV

Please upload your Government-Issued photo ID.

Please upload your malpractice declarations page.

Hours available per week:

Earliest date you can start seeing patients:

Primary time zone

Section 3: Credentialing & Digital

Which Insurance Payers are you currently credentialed with under your individual NPI?

List any payers not in the above list, or note state specific BCBS/Medicaid Plans.

Click Below:

Zocdoc profile URL (if you have one)

I want Same-Day Psych to manage my Zocdoc profile (create or take over existing.

Psychology Today profile URL (if you have one)

I want Same-Day Psych to manage my Psychology Today profile

Personal practice URL (if you have one)

Google Business profile URL (if you have one)

LinkedIn URL (if you have one)

Click below:

EPCS (Electronic Prescribing of Controlled Substances) Status

Board Certification(s)

Please upload Board Certification(s)

Comfort level with prescribing controlled substances

Any prescribing limitations we should know about

Maximum patient panel size you'd be comfortable carrying

Do you currently have an existing patient panel from another practice?

Please confirm by clicking the box below:

Please sign below: