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PLEASE NOTE: If you have any questions regarding this form, please email [email protected].
If you've made changes to Practice Information, Specialty, Board Certifications, or Affiliations, this information will also be shared with your affiliated medical staff office. They may follow-up with you if any further documentation/verification is needed.

Provider's Information

*First Name:

Middle Initial:

*Last Name:

*NPI #:

*Medical License #:

*Providers Email Address: (This will not appear on any web site)

*Gender:

*Member of RWJBH Medical Group

Yes

*Degree

*Degree:

*Degree: (Please Select all that Apply)

APN	CPNP	DDS
DMD	DMD MD	DO
DPM	FAAOS	FAAP
FACG	FACEP	FACC
FACOG	FACP	FACS
FAOCO	FCCP	FNP
MD	LCSW	LPC
MD PhD	MPH	MSN
PhD	PsyD	RD

Practice Information

*Average Cost of Office Visit:

Year practice started:

Professional Social Media and Website Links

LinkedIn Profile URL:

Facebook Profile URL:

Twitter Profile URL:

Practice Website URL:

Languages spoken at your practice

Please select all languages spoken at your practice:

Albanian	American Sign Language	Arabic	Bengali
Blish	Bulgarian	Cantonese	Chinese
Creole	Croatian	Czech	Danish
Dutch	English	Estonian	Farsi
Filipino	French	German	Greek
Gujarati	Gur	Hebrew	Hindi
Hungarian	Igbo	Italian	Japanese
Kannada	Korean	Lebanese	Malayalam
Mandarin	Marathi	Persian	Polish
Portuguese	Punjabi	Romanian	Russian
Serbian	Spanish	Swahili	Tagalog
Tai	Tamil	Telugu	Turkish
Ukranian	Urdu	Yiddish	Yoruba

Accepted Insurances

AARP Healthcare	AARP Medicare Complete (HMO)
AARP MedicareComplete Essential (HMO)	AARP MedicareComplete Plan 1 (HMO)
AARP MedicareComplete Plan 2 (HMO)	AARP MedicareComplete Plan 3 (HMO)
AARP MedicareComplete Plan 4 (HMO)	Active Care (Worker's Comp)
Aetna	Aetna Better Health
Aetna Choice POS II	Aetna Dental
Aetna Elect Choice	Aetna EPO
Aetna First Health	Aetna Health Plans of NJ
Aetna HMO	Aetna Indemnity plans with network incentives
Aetna Joint Claims Administration	Aetna Managed Choice POS
Aetna Medicare	Aetna Medicare NNJ Prime
Aetna Medicare Plan (HMO)	Aetna Medicare Plan (PPO with Extended Service)
Aetna Medicare Plan (PPO)	Aetna Meritain/Meritain Shared Administrative Services
Aetna Open Choice	Aetna Passport to Healthcare®and National Advantage
Aetna Passport to Healthcare®and National Advantage Program	Aetna POS
Aetna PPO	Aetna QPOS
Aetna Select	Aetna Signature administrators®
Aetna Student Health	Aetna US Health Care
American Postal Workers Union	America's Health Plan
Americhoice	Amerigroup
Amerigroup (Managed Medicaid Plan)	Amerihealth
Anthem Health	Anthem Health of NY
Bankers Life and Casualty	Beacon
Beech Street	BeechStreet PPO
Benefit Planners Insurance	Benesight
Blue Cross Blue Shield Omnia	Blue Cross/Blue Shield NJ
Braven Health	Centivo
Charity Care Accepted	CHN
Cigna	Cigna Behavioral Health
Cigna Health Springs	Cigna Healthcare
Cigna Healthcare of New Jersey – Northern NJ HMO	Cigna Healthcare/Great West
Cigna HMO	Cigna Medicare
Cigna Open Access Plus, Choicefund OA Plus	Cigna Open Access Plus, OA Plus, Choicefund OA Plus with CareLink
Cigna PPO, Choicefund PPO	Cigna Seamless – Metro New York
Clover	Clover Health
Community Care Network	Consumer Health Plan
Coventry	Delta Dental
Devon Health Services	DOL
Emblem	Emblem Health / GHI
Emblem Health / QualCare	Empire BC/BS
Empire Healthchoice	Empire through Blue Card Program
Erickson Advantage Champion (HMO-POS SNP)	Erickson Advantage Freedom (HMO-POS)
Erickson Advantage Guardian (HMO-POS SNP)	Erickson Advantage Signature with Drug (HMO-POS)
Erickson Advantage Signature without Drug (HMO-POS)	Evolutions Health Systems
Family Choice Health Alliance	Federal Blue Cross PPO
Fidelis (WellCare)	First Health Network
First Managed Care Option	First MCO (Worker's Comp)
First MCO/Active Care	Focus Healthcare
Galaxy Health Care	Galaxy Health Network
Genworth	GHI
GHI PPO	GHI through QualCare (only for patients where the Qualcare logo appears on ID card)
Great West Healthcare	Great-West (Cigna)
Guardian Resources Inc.	Health Net
Health Network America Inc.	Health New Federal Services
Health Republic Insurance of NJ	Healthcare Payers Coalition
Healthcare Payors Organization	Healthfirst of New Jersey
HealthNet Federal Health Services (TriCare-Champus)	HIP PPO
HMO Blue - Medicare Blue	Horizon
Horizon Advantage EPO	Horizon BCBS
Horizon Blue Cross Blue Shield HMO	Horizon Blue Cross Blue Shield Indemnity
Horizon Blue Cross Blue Shield Medicare Blue	Horizon Blue Cross Blue Shield of NJ
Horizon Blue Cross Blue Shield Omnia	Horizon Blue Cross Blue Shield PPO
Horizon Casualty	Horizon Casualty Services (Worker's Comp & No Fault)
Horizon Direct Access	Horizon EPO/EPO Plus
Horizon HMO	Horizon Managed Care
Horizon Medicare Blue (PPO)	Horizon Medicare Blue Access (HMO-POS)
Horizon Medicare Blue Advantage (HMO)	Horizon Medicare Blue Choice w/Rx (HMO)
Horizon Medicare Blue Group (PPO)	Horizon Medicare Blue Group w/Rx (PPO)
Horizon Medicare Blue Value (HMO)	Horizon Medicare Blue Value w/Rx (HMO)
Horizon MyWay HRA Direct Access	Horizon MyWay HRA PPO
Horizon MyWay HSA Direct Access	Horizon MyWay HSA PPO
Horizon NJ Health	Horizon NJ Health (managed Medicaid plan)
Horizon Patient-Centered Adv EPO	Horizon POS
Horizon PPO	Horizon Traditional/Indemnity
Humana Medicare	Humana Tricare
Independence BCBS	Intergroup Services
Liberty Mutual	Local 1199
Local 464/Maxon	Local 734
Local 825 Welfare Fund	Longevity
Lutheran Senior Healthcare	Magellan
Magellan Behavioral Health	Magnacare
Magnacare/Magnet	Mail Handlers Benefit Plan
Managed Health Network	MCS Patient Centered Health Care Network
Medicaid	Medicare
Metlife	Multiplan
Multiplan / PHCS	Multiplan/Beechstreet/PHCS/Viant
Multiplan/PHCS Savility	Mutual of Omaha
National Association of Letter Carriers	National Health Plan
National Preferred Provider Network (NPPN)/Plan Care America	National Provider Network
New Jersey Carpenters Health Fund	New Jersey Manufacturers
New Jersey Manufacturers through Horizon Casualty	New Jersey Plus
NJ 21st Century Family Cares - Medicaid	NJ Direct
NJ Direct MA PPO	No Insurance
Northwell	OMNIA
OMNIA Bronze	OMNIA Gold
OMNIA HSA	OMNIA Platinum
OMNIA Silver	OMNIA Silver HSA
Optum Behavioral Health	Oxford
Oxford Health	Oxford Health Plan HMO
Oxford Health Plan PPO	Oxford Medicare Advantage Plans
Oxford Medicare Advantage Private Fee For Service Plans	PPO Next MasterCare
Prime Health Services	Private Healthcare Systems (PHCS)
Qualcare	Qualcare HMO
QualCare POS	Qualcare PPO
QualCare Workers Comp	Railroad Medicare
State Farm	Three Rivers Health Plan
Three Rivers Provider Network	Travelers
Tricare	UHC/OX
UHCCP	United American
United Behavioral	United Community
United Healthcare	United Healthcare Charter Balanced
United Healthcare Charter HMO	United Healthcare Charter Plus
United Healthcare Choice	United Healthcare Choice Plus
United Healthcare Community Plan	United Healthcare Community Plan (formerly Americhoice Managed Medicaid)
United Healthcare Core	United Healthcare Core Essential
United Healthcare Core HMO	United Healthcare Navigate
United Healthcare Navigate Balanced	United Healthcare Navigate Plus
United Healthcare Options PPO	United Healthcare Oxford Freedom
United Healthcare Oxford Liberty	United Healthcare Oxford Metro
United Healthcare Select	United Healthcare Select Plus
United Medicare	United Medicare Advantage Plan
United Medicare Advantage Private Fee For Service Plans (PFFS)	United Payors & United Providers
UnitedHealthcare Assisted Living Plan (HMO SNP)	UnitedHealthcare Assisted Living Plan (HMO-POS SNP)
UnitedHealthcare Assisted Living Plan (PPO SNP)	UnitedHealthcare Group Medicare Advantage (HMO)
UnitedHealthcare Group Medicare Advantage (PPO)	UnitedHealthcare MedicareComplete Focus (HMO)
UnitedHealthcare Nursing Home Plan (HMO SNP)	UnitedHealthcare Nursing Home Plan (HMO-POS SNP)
UnitedHealthcare Nursing Home Plan (PPO SNP)	University Health Plan
US Family Health Plan	US Family Health Plan (Tricare Prime)
US Family Plan	USA Managed Care Organization
Value Options	Veterans Affairs Administration
WellCare	WellCare Health Plan
Wellcare Managed Medicaid (Family Care)	Wellcare Managed Medicare
Wellchoice	WellPoint (Amerigroup)

Other:

*Primary Office

*Practice name:

*Street Address:

Bldg/Suite:

*City:

*State:

*Zip:

County:

*Office Phone:

Fax#:

Hours:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Office Location #2

Practice name:

Street Address:

Bldg/Suite:

City:

State:

Zip:

County:

Office Phone:

Fax#:

Hours:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Office Location #3

Practice name:

Street Address:

Bldg/Suite:

City:

State:

Zip:

County:

Office Phone:

Fax#:

Hours:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Office Location #4

Practice name:

Street Address:

Bldg/Suite:

City:

State:

Zip:

County:

Office Phone:

Fax#:

Hours:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Remove Office Location(s)

Remove Office Location(s):

Provider's Curriculum Vitae Information

*Affiliations and Year Appointed

Year appointed:

*Affiliations:

*Please select all RWJBarnabas Health facilities you are affiliated with:

Children’s Specialized Hospital	Childrens Hospital of New Jersey at Newark Beth Israel Medical Center
Clara Maass Medical Center	Community Medical Center
Cooperman Barnabas Medical Center	Jersey City Medical Center
Monmouth Medical Center	Monmouth Medical Center Southern Campus
Newark Beth Israel Medical Center	Robert Wood Johnson University Hospital
Robert Wood Johnson Medical School	RWJBarnabas Health Medical Group
RWJ University Hospital Hamilton	RWJ University Hospital Rahway
RWJ University Hospital Somerset	The Bristol-Myers Squibb Children’s Hospital at RWJUH
The Unterberg Children’s Hospital at Monmouth Medical Center	Trinitas Regional Medical Center

Specialties

Specialties:

Please select your Specialties:

Acupuncture	Addiction Medicine	Addiction Psychiatry
Adolescent Medicine	Allergy & Immunology	Anesthesiology
Anesthesiology-Cardiac	Blood Banking/Transfusion Medicine	Bloodless Medicine
Cardiology	Cardiology-Adult Congenital Heart Disease	Cardiology-Advanced Heart Failure and Transplant
Cardiology-Interventional	Clinical BioChemical Genetics	Clinical Cardiac Electrophysiology
Clinical Neurophysiology	Critical Care Medicine	Cytopathology
Dentistry-Endodontics	Dentistry-General	Dentistry-Implant
Dentistry-Oral Surgery	Dentistry-Orthodontics	Dentistry-Periodontics
Dermatology	Dermatopathology	Electromyography
Emergency Medicine	Endocrinology-Diabetes & Metabolism	Epilepsy
Ethicist	Family Medicine	Gastroenterology
Geriatric Medicine	Gynecologic Oncology	Gynecology
Hematology	Hematopathology	Hospice and Palliative Medicine
Infectious Disease	Integrative Medicine	Internal Medicine
Interventional Pulmonology	Joint Reconstruction-Adult	Maternal & Fetal Medicine
Medical Genetics	Medical Oncology	Medical Toxicology
Neonatal-Perinatal Medicine	Nephrology	Neurodevelopmental Disabilities
Neurology	Neurology-Electrodiagnostic Medicine	Neuromuscular Medicine
Neuropathology	Neurophysiological Monitoring	Neurophysiology-Clinical
Neuroradiology	Nuclear Medicine	Nuclear Radiology
Nutrition	OB/GYN	Occupational Medicine
Occupational Therapy	Ophthalmology	Ophthalmology-Pediatrics
Optometry	Orthopedics	Otolaryngology/Ear-Nose-Throat
Pain Medicine	Pain Medicine-Anesthesiology	Pathology
Pathology-Anatomical & Clinical	Pathology-Chemical	Pathology-Forensic
Pathology-Medical Microbiology	Pathology-Molecular Genetic	Pathology-Oral
Pediatric Rehabilitation Medicine	Pediatric-Anesthesiology	Pediatric-Cardiology
Pediatric-Cardiothoracic Surgery	Pediatric-Child Abuse	Pediatric-Critical Care
Pediatric-Dentistry	Pediatric-Developmental/Behavioral	Pediatric-Emergency Medicine
Pediatric-Endocrinology	Pediatric-Gastroenterology	Pediatric-Genetics
Pediatric-Hematology/Oncology	Pediatric-Infectious Disease	Pediatric-Intensive Care
Pediatric-Nephrology	Pediatric-Neurology	Pediatric-Neurosurgery
Pediatric-Orthopedic Surgery	Pediatric-Otolaryngology	Pediatric-Pulmonology
Pediatric-Radiology	Pediatric-Rheumatology	Pediatrics
Pediatric-Surgery	Pediatric-Urology	Pedodontics
Perinatology	Physical Medicine & Rehabilitation	Physical Medicine and Rehabilitation-Electrodiagnostic Medicine
Podiatry	Prosthodontics	Psychiatry
Psychiatry-Child & Adolescent	Psychiatry-Geriatric	Psychology
Psychosomatic Medicine	Pulmonary Disease	Pulmonary-Critical Care
Radiation Oncology	Radiology	Radiology-Diagnostic
Radiology-Interventional	Radiology-Vascular & Interventional	Rehabilitation Medicine
Reproductive Endocrinology/Infertility	Rheumatology	Sleep Medicine
Spinal Cord Injury Medicine	Sports Medicine	Surgery-Arthroscopy
Surgery-Bariatric	Surgery-Bloodless	Surgery-Breast
Surgery-Burn	Surgery-Colon & Rectal	Surgery-Critical Care
Surgery-Endoscopy	Surgery-General	Surgery-Hand
Surgery-Head-Neck & Facial Plastic	Surgery-Laser	Surgery-Micro
Surgery-Minimally Invasive	Surgery-Neurological	Surgery-Oncology
Surgery-Ophthalmology	Surgery-Oral & Maxillofacial	Surgery-Plastic
Surgery-Refractive	Surgery-Robotic	Surgery-Spine
Surgery-Thoracic & Cardiac	Surgery-Total Joint Replacement	Surgery-Vascular
Transplantation	Undersea & Hyperbaric Medicine	Urogynecology
Urology	Vascular Neurology	Wound Care

Board Certifications

Board Certifications:

Please select your Board Certifications:

Addiction Medicine	Addiction Psychiatry	Adolescent Medicine
Allergy & Immunology	Anesthesiology	Blood Banking/Transfusion Medicine
Cardiology	Cardiology-Adult Congenital Heart Disease	Cardiology-Advanced Heart Failure & Transplant
Cardiology-Interventional	Clinical BioChemical Genetics	Clinical Cardiac Electrophysiology
Clinical Neurophysiology	Critical Care Medicine	Cytopathology
Dentistry-Endodontics	Dentistry-General	Dentistry-Implant
Dentistry-Oral Surgery	Dentistry-Orthodontics	Dentistry-Periodontics
Dermatology	Dermatopathology	Emergency Medicine
Endocrinology-Diabetes & Metabolism	Epilepsy	Family Medicine
Gastroenterology	Geriatric Medicine	Gynecologic Oncology
Gynecology	Hematology	Hematopathology
Hospice & Palliative Medicine	Infectious Disease	Internal Medicine
Maternal & Fetal Medicine	Medical Oncology	Medical Toxicology
Neonatal-Perinatal Medicine	Nephrology	Neurodevelopmental Disabilities
Neurology	Neuromuscular Medicine	Neuropathology
Neurophysiology-Clinical	Neuroradiology	Nuclear Medicine
Nuclear Radiology	OB/GYN	Occupational Medicine
Ophthalmology	Orthopedics	Otolaryngology/Ear-Nose-Throat
Pain Medicine	Pain Medicine-Anesthesiology	Pathology
Pathology-Anatomical & Clinical	Pathology-Chemical	Pathology-Forensic
Pathology-Medical Microbiology	Pathology-Molecular Genetic	Pathology-Oral
Pediatric-Cardiology	Pediatric-Child Abuse	Pediatric-Critical Care
Pediatric-Dentistry	Pediatric-Developmental/Behavioral	Pediatric-Emergency Medicine
Pediatric-Endocrinology	Pediatric-Gastroenterology	Pediatric-Hematology/Oncology
Pediatric-Infectious Disease	Pediatric-Nephrology	Pediatric-Otolaryngology
Pediatric-Pulmonology	Pediatric-Radiology	Pediatric-Rehabilitation Medicine
Pediatric-Rheumatology	Pediatrics	Pediatric-Surgery
Pediatric-Urology	Physical Medicine & Rehabilitation	Podiatry
Prosthodontics	Psychiatry	Psychiatry-Child & Adolescent
Psychiatry-Geriatric	Psychosomatic Medicine	Pulmonary Disease
Radiation Oncology	Radiology-Diagnostic	Radiology-Interventional
Radiology-Vascular & Interventional	Reproductive Endocrinology/Infertility	Rheumatology
Sleep Medicine	Spinal Cord Injury Medicine	Sports Medicine
Surgery-Colon & Rectal	Surgery-Critical Care	Surgery-General
Surgery-Hand	Surgery-Head-Neck & Facial Plastic	Surgery-Neurological
Surgery-Oncology	Surgery-Oral & Maxillofacial	Surgery-Plastic
Surgery-Thoracic & Cardiac	Surgery-Vascular	Undersea & Hyperbaric Medicine
Urology	Vascular Neurology

Education and Training

Please enter all 4 education fields using the following format: 'Institution, State/Province, Country, Year'

e.g., ABC Medical School, NJ, United States, 2014

Medical School(s):

Internship(s):

Residency(s):

Fellowship(s):

Biography

Biography:

Clinical Interests

Clinical Interests:

Professional Image

Upload professional image:

NOTE: Photos must meet the following criteria:

Formal headshot in a white coat or professional attire.
Image files must be in .jpg, .gif or .tiff format (at a resolution of at least 300 dpi).
The image must be at least 500 pixels wide and less than 3mb in file size.

If you need a professional photo taken, please contact your affiliated hospital’s Marketing Dept. and they can arrange for your photo.

Publications

Publications:

Philosophy of Care Statement

Philosophy of Care Statement:

Form Verification Information

*Name of individual completing this form:

*Phone:

*Administrative email:(This will not appear on any web site)

*Confirm Security Question below: