RMS Individual Provider Profile

1
We look forward to working with you and require some additional information to begin our process. Information required is as follows:

Email

Home Address

Contact Numbers

Individual NPI

CAQH Number / Login / Password

Date of birth

Country/State of birth

SSN

Academic training information (name/graduation month, date and year)

Professional license information (Upload Required)

Certificate of Insurance (Upload Required)

Certification(s) (Upload Required)

DEA Number

Practice location

Group/Practice NPI

Credentialing Status

Driver License (Upload Required)

Curriculum Vitae (CV) / Resume (Upload Required)

If all required information available, please begin the process.
2
Name of Person Completing This Form* This field is required.
First Name
Last Name
3
Email* This field is required.
youremail@domain.com
4
National Provider Identifier (NPI)* This field is required.
5
Council for Affordable Quality Healthcare ( CAQH) Number* This field is required.
6
Council for Affordable Quality Healthcare ( CAQH) Login* This field is required.
7
Council for Affordable Quality Healthcare ( CAQH) Password* This field is required.
8
Legal Name of Provider on File with SSA* This field is required.
First Name
Last Name
9
Date of Birth* This field is required.
10
Sex* This field is required.
Male
Female
11
SS#* This field is required.
12
Country of Birth* This field is required.
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (fmr. "Swaziland")
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
13
State/Territory of Birth* This field is required.
14
Provider Home Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Phone Number* This field is required.
16
Upload Driver License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Name of Medical School * This field is required.
18
Graduation Year* This field is required.
19
Medical License Number * This field is required.
20
Original Effective Date* This field is required.
21
Renewal Date* This field is required.
22
State where issued* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
23
Specialty* This field is required.
Behavioral Health
Cardiology
Certified Nursing Assistant (CNA)
Critical Care
Endocrinology
Family Practice
Home Health Aide (HHA)
Internal Medicine
OB/GYN
Nephrology
Neurology / Stroke
Nurse Practitioner
Nutritionist
Palliative Care
Pharmacist
Pulmonary
Psychiatry
Psychology
Registered Dietian
24
Upload Medical License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
25
Do you currently have Board Certification?* This field is required.
YESNO
26
Name of Certification Board* This field is required.
Allergy and Immunology
Anesthesiology
Colon and Rectal Surgery
Dermatology
Emergency Medicine
Family Medicine
Internal Medicine
Medical Genetics and Genomics
Neurological Surgery
Neuromusculoskeletal Medicine
Nuclear Medicine
Obstetrics and Gynecology
Ophthalmology
Orthopaedic Surgery
Otolaryngology – Head and Neck Surgery
Pathology
Pediatrics
Physical Medicine and Rehabilitation
Plastic Surgery
Preventive Medicine
Proctology
Psychiatry and Neurology
Radiology
Surgery
Thoracic Surgery
Urology
27
Original Effective Date* This field is required.
28
Renewal date* This field is required.
29
State where issued* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
30
Upload Certification* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
31
Do you currently have a DEA Number?* This field is required.
YESNO
32
DEA Number* This field is required.
33
State where issued* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
34
Effective Date
35
Expiration Date* This field is required.
36
Upload Certificate of Insurance / Proof of Insurance
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
37
Medicare-imposed revocation of any Medicare billing privileges?* This field is required.
YESNO
38
Suspension or revocation of a license to provide health care by any State licensing authority?* This field is required.
YESNO
39
Revocation or suspension by an accreditation organization?* This field is required.
YESNO
40
Conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment?* This field is required.
YESNO
41
An exclusion or debarment from participation in a Federal or State health care program?* This field is required.
YESNO
42
Do you have a Independent / Group / Practice location?* This field is required.Also, provide virtual location(s).
YESNO
43
Name of Practice / Facility* This field is required.
44
Group /Practice NPI
45
Group / Practice TIN
46
Medical Practice Location* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
47
Office Phone Number* This field is required.
48
Office Fax Number
49
Upload CV* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
50
Are you currently credentialed with Aetna?* This field is required.
YESNO
51
Are you currently credentialed with BCBS?* This field is required.
YESNO
52
Are you currently credentialed with Cigna?* This field is required.
YESNO
53
Are you currently credentialed with Humana?* This field is required.
YESNO
54
Are you currently credentialed with Medicaid?* This field is required.
YESNO
55
Are you currently credentialed with Medicare?* This field is required.
YESNO
56
Are you currently credentialed with Molina?* This field is required.
YESNO
57
Are you currently credentialed with Staywell / Wellcare?* This field is required.
YESNO
58
Are you currently credentialed with Sunshine Health?* This field is required.
YESNO
59
Are you currently credentialed with United Healthcare?* This field is required.
YESNO
60
Are you seeking credentialing Services?* This field is required.
YESNO
61
Carriers* This field is required.Please select the plan and policy type you care seeking.
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Aetna Better Health
Blue Cross / Blue Shield
Bright Health
Cigna
Devoted Health
Freedom Health
Humana
Medicaid
Medicare
Molina Healthcare, Inc.
Oscar Health
Simply Health Plan
Staywell
Sunshine Health
Tricare
United Healthcare
Wellcare
Aetna Better Health
Blue Cross / Blue Shield
Bright Health
Cigna
Devoted Health
Freedom Health
Humana
Medicaid
Medicare
Molina Healthcare, Inc.
Oscar Health
Simply Health Plan
Staywell
Sunshine Health
Tricare
United Healthcare
Wellcare
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
Select Plan
Commercial
Medicaid MMA
Medicare MMA
1 of 17
62
Signature* This field is required.I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of services provided.
Clear
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