Clinician Application
Please complete all fields and upload the required documents before submitting. Have your license, insurance certificate, clearances, and CAQH information ready.
How to Obtain Required Documents
- Clinical License Download from the PA Dept. of State license portal. Log in and print your current license certificate.
- Proof of Insurance Request a certificate of insurance from your malpractice carrier (e.g. HPSO, CPH&A, Berkley). Must show $1M/$3M limits.
- Social Security Card Use your physical card or request a replacement at ssa.gov.
- PA State Police Clearance Apply online at epatch.pa.gov. Results are emailed within minutes. Cost: $22.
- PA Child Abuse Clearance (PATCH) Apply at compass.state.pa.us under "Child Abuse History Clearance." Cost: $13 (or free for volunteers).
- FBI Background Check (IdentoGO) Schedule fingerprinting at identogo.com using PA service code 1KG756 (childcare/human services). Bring a valid photo ID. Cost: ~$23.
- CAQH Number & Profile Register or log in at proview.caqh.org. Your CAQH number is on your dashboard. Attach a screenshot or PDF of your completed profile.
- Insurance Credentialing Form This will be provided to you by The Kaizen Clinic after your initial application is reviewed. Upload a signed copy here if you have already received it.