Work Comp Doctors - How to get listed application - Our Workers' Compensation medical providers are knowledgeable in the medical and legal responsibilities and reporting for the workers' compensation industry.

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Where Responsible Providers Help Employers & Administrators

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	Application Instructions
	Step 1 . Once you complete this form you will submit it for review.
	Step 2 . If approved you practice will be contacted.
	Step 3 . We will contact you with potential patients.

Expand Your Web Presence
List your practice with WorkCompDocs.com

Simplicity. The one-stop location designed specifically for Worker's Compensation Doctors, their patients and referral sources. WCD.com is a showcase for physicians to display their credentials, insurance networks, and locations, simplifying the process for all three parties and eliminating the potential for a case to be dropped.

Visibility. Here, you are number one on the search engine. Typical search engines may place you on page 3 to 100 of a search for a local Doctor, but here you are placed at the top of any search for doctors that service workers compensation cases.

Accessibility. Our dedicated staff and surgeons have years of experience with Insurance Providers, Injured Workers, and the guidelines that define and rule the world of Worker's Compensation. Our staff is available to assist you through our toll free phone service and online, 24/7 to answer your questions with quick and effective service.

Marketing. Our physician listing includes all the information you input into the form below, including your photo, personal physician statement, Curriculum Vitae, Medical Provider Network List, and office locations. We excel at retaining effective referral sources that drive our business.

Physician Listing Application Form

Business Information (Information in this section may be publicly viewable) *Required Fields

What is the name of your treatment facility?

Names of the physician(s)? (include degrees)

Office location address #1:

	Street	Unit (ex: Suite 100)

	City	State Zip Code

Office location address #2:

	Street	Unit (ex: Suite 100)

	City	State Zip Code

Office location address #3:

	Street	Unit (ex: Suite 100)

	City	State Zip Code

What is the facility's web site address? (ex: www.myfacility.com)

The facility has no web site, but
would like help creating one:

Describe your treatment facility in 20 words or less.

What percentage of this facility's practice is devoted to workers comp cases?

less than 50%

50% - 69%

70% - 90%

more than 90%

How many physicians practice at this facility?

How many years has this facility's most experienced physician been practicing?

Please select what specialty(ies) are practiced at your facility?

select	Type of procedure
	Acupuncture
	Bariatrics
	Chiropractic
	Dentistry
	Diagnostic Testing
	Emergency Services
	Internal Medicine
	Massage Therapy
	Neurology
	Ophthalmology
	Orthopedics
	Pain Management
	Pharmacy
	Physical Therapy
	Podiatry
	Post-Treatment Life Change Programs
	Psychology
	Sports Medicine
	Surgery
	Transportation
Enter other Specialties here
Enter other Specialties here
Enter other Specialties here

Person to Contact (for administration purposes only not viewable by the public)

* Name

* Doctors Last Name

* Email Address (Note: Patient leads will be forwarded to this address)

* Phone

Best time to call

Fax

CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
Please list in reverse chronological order (with the current affiliation{s} first) all institutions where you have current affiliations (A) and have had previous hospital privileges (B) during the past ten years. This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies.
A. CURRENT AFFILIATIONS

Name of Primary Admitting Hospital / and Mailing Address:		City:
		State:	ZIP:
Department/Status (active, provisional, courtesy, etc.):		Appointment Date:
Name of Other Hospital/Institution / and Mailing Address:		City:
		State:	ZIP:
Department/Status:		Appointment Date:
Name of Other Hospital/Institution and Mailing Address:		City:
		State:	ZIP:
Department/Status:		Appointment Date:
If you do not have hospital privileges, please explain on Addendum A.
B. PREVIOUS AFFILIATIONS During Last Ten Years.
Name of Other Hospital/Institution /and Mailing Address:		City:
		State:	ZIP:
From: (mm/yy)	To: (mm/yy)	Reason for Leaving:
Name of Other Hospital/Institution and Mailing Address:		City:
		State:	ZIP:
From: (mm/yy)	To: (mm/yy)	Reason for Leaving:

MEDICAL LICENSURE/REGISTRATIONS
California State Medical License Number:	Issue Date:	Expiration Date:
Drug Enforcement Administration (DEA) Registration Number:		Expiration Date:
Controlled Dangerous Substances Certificate (CDS) (if applicable):		Expiration Date:
ECFMG Number (applicable to foreign medical graduates):		Date Issued:
		Valid Through:
Medicare UPIN/National Physician Identifier (NPI):		MediCal/Medicaid Number:

Other Information

Please enter any comments or questions

Other than the physicians at your facility, if you had to see a physician, who would you recommend?

Name City State