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  1. Provider  
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  2. Referral  
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  3. Practice  
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  4. Education  
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  5. License/Certification  
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  6. Insurance  
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  7. Work History  
  8. EAP Counselor  
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  9. Disability Provider  
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  10. FFD Specialist  
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  11. Provider Profile  
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  12. Attestation  
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  13. W-9  

4. EDUCATION INFORMATION (Required for verification purposes)
Educational Degrees:
A. EDUCATION INFORMATION
Edit Type Institution Degree Start End Delete
No Records Found
 
 
 
If you are a foreign medical school graduate, are you certified by the Educational Commission for Foreign Medical Graduates (ECFMG)? Yes No
 
* If the answer is yes, please include a copy of your certificate. If you have an electronic copy of your certificate, please use the Upload ECFMG button. If you have a paper copy of your certificate, please fax it to 866-612-7795.
 
 
B. CONTINUING EDUCATION: This section is required for EAP Applicants Only. List any continuing education seminars/workshops you have attended in the past 24 months. Please upload a copy of CEU/PDH certificate(s) of completion or you may attach a copy of your Accredited Continuing Education Agency's Report, if applicable. If you do not have electronic copies of either your CEU/PDH certificate or your Accredited Continuing Education Agency's Report, please fax the paper copies to 866-612-7795.
 
Edit Course Sponsor CEUs Title Date Completed Delete
No Records Found
 
 
 
 
  
 
 

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