Medical Resource Specialists - MED-SOURCE, INC.

Provider Information Form

As noted, Med-source, Inc. specializes in scheduling various types of consulting services for our clients. Our company strives to provide honest, unbiased reporting from ethical and responsible clinicians who take this work seriously and professionally. Every provider must maintain an active private practice and keep abreast of current developments germane to their respective specialties. Providers must be board certified; dual or more certification plus fellowship training is a plus! All reports are written by YOU, the examining provider, in your own format and letterhead. All referrals are made on a case-by-case basis.

Med-source, Inc. is continually seeking providers who have interests in performing such services. Should you wish to join our panel, please complete the online information OR mail/FAX the following documents:

Current Curriculum Vitae
Verification of Malpractice Insurance Coverage
For examinations done in your own office: a copy of your office General Liability Coverage
W-9 Taxpayer Identification
Copy of Board Certification(s)
Medical License(s)
Workers' Compensation Certification
Workers' Compensation IME Certification (NYS Providers)
Full contact information including email and website addresses.
Fees
Let us know if:
1. You are willing to do examinations in other offices than your own and...
2. would you consider doing examinations in our West Nyack office.

By providing us with this information, after careful review, you may join our panel of providers. Please note that the information you are submitting is SECURE.

Provider's First Name:

Provider's Last Name:

EMAIL address:

Office Address:

Suite, Apt, Box, Etc. (if applicable):

City: , State:

Zip Code :

Office Phone:

Office FAX:

Mailing Address Information:
(If different than information listed above)

Mailing Address:

Mailing Suite, Apt, Box, Etc. (if applicable):

Mailing City: , State:

Mailing Zip Code:

Specialty:

Subspecialty:

Do you perform Worker's Comp Exams?

YES

Will you perform Liability Exams?

YES

What is your fee for an Exam & Report?

Name of Contact to schedule exams:

What is your fee for a No Show?

What is your fee for a Reevaluation?

What is your Worker's Comp rating?

TAX ID#:

Are you Board Certified?

YES

Are you currently in Private Practice?

YES

Language(s) spoken:

Are fees standard for all Vendors?

YES

Will you testify?

YES

What are your fees for testifying?
(please answer below)

Testifying for a half day?
Testifying for a full day?

Any biomechanical (MVA/CAUSALITY) training?
(please state briefly)

Any additional Qualifications or Training?