New Diagnostician Setup Form Diagnostician's Information Below you will need to upload 1.) your License AND 2.) your Professional Liability Insurance. First Name*Last Name*Your Email* Your Phone*Your Date of Birth*Your Social Security Number*Your Gender*MaleFemaleYour Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Individual NPI #Your Credentials (abbreviations)*Your Taxonomy CodeDo you have a CAQH account set up yet?*YesNoIf yes, please list username and password:Insurance Companies in network withPlease list the name of all the insurance companies that you were in network with at your last job.What is the day you started working/will start at this new clinic?*(First date treating patients) Date Format: MM slash DD slash YYYY Upload your 1.) License AND 2.) Professional Liability Insurance* Drop files here or NameThis field is for validation purposes and should be left unchanged.