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: