Peer Review Solutions, Inc.

1630 North Main St., #377
Walnut Creek, CA 94596-4609

Toll Free: 888-950-PEER(7337)

info@peerreviewsolutions.com

 

URAC
Reviewer Application
*Required
Reviewer Name: * DOB: / / *
Former names used: Gender: M F
NPI #:  
Referred By:
Organization:   Name:   Email:
1. Contact information:
Office phone: *   Office Contact Person: *
Cell phone: *   Pager:
Fax:
Email: *
Alternate Email:
2. Street or office address for delivery of cases (PLEASE DO NOT PROVIDE P.O. BOX):
Address: *
Address2:
City: *   State: *   Zip: *
3. Mailing address where you would like to receive your checks:
Address:
Address2:
City:     State:     Zip:
4. General Statements:
I will notify the office immediately if there is a possible conflict of interest. *
I will be available to work in the time frame of 3 to 4 days for standard reviews. *
I will be willing to speak with the provider of service as requested by PRS. *
I am available to do expedited reviews (24-72 hours) as requested by PRS. *
I am willing to receive cases electronically (via secure email/secure web link). *
Yes
No
I am interested in receiving my checks via direct deposit.
Yes
No
Are you fluent in any foreign languages?
Please list:
Yes No   I work in active practice at least ten hours per week? If not, please indicate the number of hours per week:
I will notify PRS immediately of any possible conflict of interest issue with any case assigned to me. (as defined in the Conflict of Interest Agreement). *
5. List Specialties:
Select a specialty:
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6. Board Certification: List recognized board, certification and expiration dates
1) *   Issue Date: / / *   Exp. Date: / /
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7. Please list all States where licensed:
1) *   License #:     Active Inactive
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* Please click "add more" to list additional licenses with activity.
8. Please list all current Federal and State drug registrations below:
Drug enforcement Administration:
1. Certificate Number:
2. Issue Date: / /   Exp. Date: / /
State Controlled Substance Registration:
1. Certificate Number:
2. Issue Date: / /   Exp. Date: / /
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9. Upload supporting documentation or required forms to accompany your application. Please note that the "Save" button will not save documents!
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