Physician Reviewer Application

Interested in Joining HQSI’s Physician Reviewer Network?

Complete the form below to apply for our Physician Reviewer Network.

 

Contact Information

First Name (required)

Last Name (required)

Credentials (required)

Email Address (required)

Phone Number

Your License Number (required)


Please list all of the states you are currently licensed in and provide your license number for each state.

Your NPI Number


What is your specialty?

Enter your Board certifications

I certify that:
I hold an unrestricted license to practice medicine in the United States.I hold a current board certification as listed under Qualifications.I have a minimum of five (5) years of independent practice and experience in the applicable board certified clinical specialty with recent clinical experience within the past three (3) yearsI have no history of disciplinary actions.

Referred by:


Upload a current copy of C.V. (jpg, pdf, docx, xlsx or csv - 500k max: