Welcome to the TrueEval Provider Network.

This application is designed to capture all necessary credentials, licensing, malpractice coverage, and service readiness to ensure you are eligible to provide telehealth consultations through TrueEval. Completion of this application establishes your profile for onboarding and credentialing but does not constitute an employment contract.

Personal Information

Please provide your current contact information. This will be used for credentialing and compliance communication.

First Name

Last Name

Phone *

Email *

Gender *

Male

Female

Date of birth *

Address

Street Address

City

State

Country

Postal Code

Professional Credentials

Note: If you hold multiple state licenses or DEA registrations, please upload your complete license roster in CSV or Excel format only. This allows us to securely import your information into our system and prevents manual data entry errors. PDFs, images, and Word documents are not accepted.

NPI Number

DEA Number

Medical Degree/Title

Specialty or Primary Area of Practice

Sub-specialty / Certifications

Languages Spoken

Years in Practice

DEA Certificate Upload

State Licensure

Note: If you hold multiple state licenses or DEA registrations, please upload your complete license roster in CSV or Excel format only. This allows us to securely import your information into our system and prevents manual data entry errors. PDFs, images, and Word documents are not accepted.

License States

License Number

License Expiration Date

State License Documents

Upload License Copy

Collaborative Licenses Fields:

Do you have a collaborating physician for any of your licensed states?

Yes

No

Collaborative License State

Please Upload Collaboration Agreements

Check:

Need Collaborator Provided

Malpractice Insurance

Please confirm your malpractice coverage status and upload a copy of your current certificate for verification.

Malpractice Coverage Active?

Yes

No

Upload Malpractice Certificate

Do you need malpractice coverage arranged by TrueEval?

Yes

No

Work Preferences

Please indicate how you prefer to conduct visits and the average number of patients you can see per week.

Preferred Visit Mode

Weekly Visit Capacity

Documentation

Upload Resume/CV

Upload Headshot

Upload Additional Documents

Compliance and Disclosures

Have you ever been subject to disciplinary action by a licensing board or professional body?

Yes

No

Discipilinary Action Agency

Discipilinary Action Year

Discipilinary Action Outcome

Do you have a history of malpractice claims?

Yes

No

Malpractice Claim Date

Nature of Malpractice Claim

Resolution of Malpractice Claim

Are you currently under investigation by any licensing board, employer, or regulatory agency?

Yes

No

Investigation Details

Terms and Agreement

Agreement Checkbox *

I certify the information provided is true. I authorize verification. I acknowledge this is onboarding, not employment.

Signature Capture: *