MySpecialtyDoc

Provider Applicant Form

Complete all required fields. Add every active state license and upload a current copy for each state.

Applicant Information

Legal first nameMiddle nameLegal last namePhone numberEmail address

Preferred contact method *

EmailPhoneEither

Address line 1Address line 2CityStateZIP codeDate of birth

Professional Information

Provider type *

MDDONurse Practitioner (APRN)PA

Professional credential(s)Primary specialtyNPI numberYears in practice

Relevant Experience

Select any areas where you have prior experience.

HRT GLP-1

Experience is not required. MySpecialtyDoc can train approved providers.

Active State Licenses

Add every active professional license you currently hold. Each entry requires its own document upload.

State license 1

State *License typeLicense numberExpiration date

Upload license document *Drag and drop files here or browse filesPDF, JPG, JPEG, or PNG.

Prescribing Credentials — Complete if Applicable

Do you currently hold an active DEA registration? *

YesNo

Do you hold any state controlled-substance registrations separate from your professional license?

YesNoNot sure

Resume and Background

Upload resume / CV *Drag and drop files here or browse filesPDF, JPG, JPEG, or PNG. Multiple files allowed.Upload headshot (profile photo) *Drag and drop files here or browse filesJPG, JPEG, or PNG. This photo may be used for your provider profile if approved.Upload additional supporting documentsDrag and drop files here or browse filesOptional. PDF, JPG, JPEG, or PNG. Multiple files allowed.

Has any licensing board, certifying body, hospital, employer, or professional agency ever taken disciplinary action against you? *

YesNo

Is any professional license, certification, registration, or clinical privilege currently restricted, limited, suspended, on probation, voluntarily surrendered, or under investigation? *

YesNo

If yes to either background question, explain

Attestation and Signature

I certify that the information provided is true and complete. I authorize the organization to verify my identity, licenses, certifications, NPI, prescribing credentials, disciplinary history, and professional qualifications through appropriate sources.I understand that the organization will review my credentials and all applicable state practice and prescribing requirements. I will not provide patient care or prescribe in any state until the organization confirms that I have been approved and activated for that state.

Electronic signaturePrinted legal nameDate

Submitting this form starts a credentials review. It does not grant provider access or approve you to see patients.

Provider Applicant Form | HRT & GLP-1 Care