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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 YesNo

*Degree

*Degree:

*Degree: (Please Select all that Apply)

APNCPNPDDS
DMDDMD MDDO
DPMFAAOSFAAP
FACGFACEPFACC
FACOGFACPFACS
FAOCOFCCPFNP
MDLCSWLPC
MD PhDMPHMSN
PhDPsyDRD

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: AlbanianAmerican Sign LanguageArabicBengali
BlishBulgarianCantoneseChinese
CreoleCroatianCzechDanish
DutchEnglishEstonianFarsi
FilipinoFrenchGermanGreek
GujaratiGurHebrewHindi
HungarianIgboItalianJapanese
KannadaKoreanLebaneseMalayalam
MandarinMarathiPersianPolish
PortuguesePunjabiRomanianRussian
SerbianSpanishSwahiliTagalog
TaiTamilTeluguTurkish
UkranianUrduYiddishYoruba

Accepted Insurances

AARP HealthcareAARP 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)
AetnaAetna Better Health
Aetna Choice POS IIAetna Dental
Aetna Elect ChoiceAetna EPO
Aetna First HealthAetna Health Plans of NJ
Aetna HMOAetna Indemnity plans with network incentives
Aetna Joint Claims AdministrationAetna Managed Choice POS
Aetna MedicareAetna 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 ChoiceAetna Passport to Healthcare®and National Advantage
Aetna Passport to Healthcare®and National Advantage ProgramAetna POS
Aetna PPOAetna QPOS
Aetna SelectAetna Signature administrators®
Aetna Student HealthAetna US Health Care
American Postal Workers UnionAmerica's Health Plan
AmerichoiceAmerigroup
Amerigroup (Managed Medicaid Plan)Amerihealth
Anthem HealthAnthem Health of NY
Bankers Life and CasualtyBeacon
Beech StreetBeechStreet PPO
Benefit Planners InsuranceBenesight
Blue Cross Blue Shield OmniaBlue Cross/Blue Shield NJ
Braven HealthCentivo
Charity Care AcceptedCHN
CignaCigna Behavioral Health
Cigna Health SpringsCigna Healthcare
Cigna Healthcare of New Jersey – Northern NJ HMOCigna Healthcare/Great West
Cigna HMOCigna Medicare
Cigna Open Access Plus, Choicefund OA PlusCigna Open Access Plus, OA Plus, Choicefund OA Plus with CareLink
Cigna PPO, Choicefund PPOCigna Seamless – Metro New York
CloverClover Health
Community Care NetworkConsumer Health Plan
CoventryDelta Dental
Devon Health ServicesDOL
EmblemEmblem Health / GHI
Emblem Health / QualCareEmpire BC/BS
Empire HealthchoiceEmpire 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 AllianceFederal Blue Cross PPO
Fidelis (WellCare)First Health Network
First Managed Care OptionFirst MCO (Worker's Comp)
First MCO/Active CareFocus Healthcare
Galaxy Health CareGalaxy Health Network
GenworthGHI
GHI PPOGHI through QualCare (only for patients where the Qualcare logo appears on ID card)
Great West HealthcareGreat-West (Cigna)
Guardian Resources Inc.Health Net
Health Network America Inc.Health New Federal Services
Health Republic Insurance of NJHealthcare Payers Coalition
Healthcare Payors OrganizationHealthfirst of New Jersey
HealthNet Federal Health Services (TriCare-Champus)HIP PPO
HMO Blue - Medicare BlueHorizon
Horizon Advantage EPOHorizon BCBS
Horizon Blue Cross Blue Shield HMOHorizon Blue Cross Blue Shield Indemnity
Horizon Blue Cross Blue Shield Medicare BlueHorizon Blue Cross Blue Shield of NJ
Horizon Blue Cross Blue Shield OmniaHorizon Blue Cross Blue Shield PPO
Horizon CasualtyHorizon Casualty Services (Worker's Comp & No Fault)
Horizon Direct AccessHorizon EPO/EPO Plus
Horizon HMOHorizon 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 AccessHorizon MyWay HRA PPO
Horizon MyWay HSA Direct AccessHorizon MyWay HSA PPO
Horizon NJ HealthHorizon NJ Health (managed Medicaid plan)
Horizon Patient-Centered Adv EPOHorizon POS
Horizon PPOHorizon Traditional/Indemnity
Humana MedicareHumana Tricare
Independence BCBSIntergroup Services
Liberty MutualLocal 1199
Local 464/MaxonLocal 734
Local 825 Welfare FundLongevity
Lutheran Senior HealthcareMagellan
Magellan Behavioral HealthMagnacare
Magnacare/MagnetMail Handlers Benefit Plan
Managed Health NetworkMCS Patient Centered Health Care Network
MedicaidMedicare
MetlifeMultiplan
Multiplan / PHCSMultiplan/Beechstreet/PHCS/Viant
Multiplan/PHCS SavilityMutual of Omaha
National Association of Letter CarriersNational Health Plan
National Preferred Provider Network (NPPN)/Plan Care AmericaNational Provider Network
New Jersey Carpenters Health FundNew Jersey Manufacturers
New Jersey Manufacturers through Horizon CasualtyNew Jersey Plus
NJ 21st Century Family Cares - MedicaidNJ Direct
NJ Direct MA PPONo Insurance
NorthwellOMNIA
OMNIA BronzeOMNIA Gold
OMNIA HSAOMNIA Platinum
OMNIA SilverOMNIA Silver HSA
Optum Behavioral HealthOxford
Oxford HealthOxford Health Plan HMO
Oxford Health Plan PPOOxford Medicare Advantage Plans
Oxford Medicare Advantage Private Fee For Service PlansPPO Next MasterCare
Prime Health ServicesPrivate Healthcare Systems (PHCS)
QualcareQualcare HMO
QualCare POSQualcare PPO
QualCare Workers CompRailroad Medicare
State FarmThree Rivers Health Plan
Three Rivers Provider NetworkTravelers
TricareUHC/OX
UHCCPUnited American
United BehavioralUnited Community
United HealthcareUnited Healthcare Charter Balanced
United Healthcare Charter HMOUnited Healthcare Charter Plus
United Healthcare ChoiceUnited Healthcare Choice Plus
United Healthcare Community PlanUnited Healthcare Community Plan (formerly Americhoice Managed Medicaid)
United Healthcare CoreUnited Healthcare Core Essential
United Healthcare Core HMOUnited Healthcare Navigate
United Healthcare Navigate BalancedUnited Healthcare Navigate Plus
United Healthcare Options PPOUnited Healthcare Oxford Freedom
United Healthcare Oxford LibertyUnited Healthcare Oxford Metro
United Healthcare SelectUnited Healthcare Select Plus
United MedicareUnited 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 PlanUS Family Health Plan (Tricare Prime)
US Family PlanUSA Managed Care Organization
Value OptionsVeterans Affairs Administration
WellCareWellCare Health Plan
Wellcare Managed Medicaid (Family Care)Wellcare Managed Medicare
WellchoiceWellPoint (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 CenterCommunity Medical Center
Cooperman Barnabas Medical CenterJersey City Medical Center
Monmouth Medical CenterMonmouth Medical Center Southern Campus
Newark Beth Israel Medical CenterRobert Wood Johnson University Hospital
Robert Wood Johnson Medical SchoolRWJBarnabas Health Medical Group
RWJ University Hospital HamiltonRWJ University Hospital Rahway
RWJ University Hospital SomersetThe Bristol-Myers Squibb Children’s Hospital at RWJUH
The Unterberg Children’s Hospital at Monmouth Medical CenterTrinitas Regional Medical Center

Specialties

Specialties:

Please select your Specialties:

AcupunctureAddiction MedicineAddiction Psychiatry
Adolescent MedicineAllergy & ImmunologyAnesthesiology
Anesthesiology-CardiacBlood Banking/Transfusion MedicineBloodless Medicine
CardiologyCardiology-Adult Congenital Heart DiseaseCardiology-Advanced Heart Failure and Transplant
Cardiology-InterventionalClinical BioChemical GeneticsClinical Cardiac Electrophysiology
Clinical NeurophysiologyCritical Care MedicineCytopathology
Dentistry-EndodonticsDentistry-GeneralDentistry-Implant
Dentistry-Oral SurgeryDentistry-OrthodonticsDentistry-Periodontics
DermatologyDermatopathologyElectromyography
Emergency MedicineEndocrinology-Diabetes & MetabolismEpilepsy
EthicistFamily MedicineGastroenterology
Geriatric MedicineGynecologic OncologyGynecology
HematologyHematopathologyHospice and Palliative Medicine
Infectious DiseaseIntegrative MedicineInternal Medicine
Interventional PulmonologyJoint Reconstruction-AdultMaternal & Fetal Medicine
Medical GeneticsMedical OncologyMedical Toxicology
Neonatal-Perinatal MedicineNephrologyNeurodevelopmental Disabilities
NeurologyNeurology-Electrodiagnostic MedicineNeuromuscular Medicine
NeuropathologyNeurophysiological MonitoringNeurophysiology-Clinical
NeuroradiologyNuclear MedicineNuclear Radiology
NutritionOB/GYNOccupational Medicine
Occupational TherapyOphthalmologyOphthalmology-Pediatrics
OptometryOrthopedicsOtolaryngology/Ear-Nose-Throat
Pain MedicinePain Medicine-AnesthesiologyPathology
Pathology-Anatomical & ClinicalPathology-ChemicalPathology-Forensic
Pathology-Medical MicrobiologyPathology-Molecular GeneticPathology-Oral
Pediatric Rehabilitation MedicinePediatric-AnesthesiologyPediatric-Cardiology
Pediatric-Cardiothoracic SurgeryPediatric-Child AbusePediatric-Critical Care
Pediatric-DentistryPediatric-Developmental/BehavioralPediatric-Emergency Medicine
Pediatric-EndocrinologyPediatric-GastroenterologyPediatric-Genetics
Pediatric-Hematology/OncologyPediatric-Infectious DiseasePediatric-Intensive Care
Pediatric-NephrologyPediatric-NeurologyPediatric-Neurosurgery
Pediatric-Orthopedic SurgeryPediatric-OtolaryngologyPediatric-Pulmonology
Pediatric-RadiologyPediatric-RheumatologyPediatrics
Pediatric-SurgeryPediatric-UrologyPedodontics
PerinatologyPhysical Medicine & RehabilitationPhysical Medicine and Rehabilitation-Electrodiagnostic Medicine
PodiatryProsthodonticsPsychiatry
Psychiatry-Child & AdolescentPsychiatry-GeriatricPsychology
Psychosomatic MedicinePulmonary DiseasePulmonary-Critical Care
Radiation OncologyRadiologyRadiology-Diagnostic
Radiology-InterventionalRadiology-Vascular & InterventionalRehabilitation Medicine
Reproductive Endocrinology/InfertilityRheumatologySleep Medicine
Spinal Cord Injury MedicineSports MedicineSurgery-Arthroscopy
Surgery-BariatricSurgery-BloodlessSurgery-Breast
Surgery-BurnSurgery-Colon & RectalSurgery-Critical Care
Surgery-EndoscopySurgery-GeneralSurgery-Hand
Surgery-Head-Neck & Facial PlasticSurgery-LaserSurgery-Micro
Surgery-Minimally InvasiveSurgery-NeurologicalSurgery-Oncology
Surgery-OphthalmologySurgery-Oral & MaxillofacialSurgery-Plastic
Surgery-RefractiveSurgery-RoboticSurgery-Spine
Surgery-Thoracic & CardiacSurgery-Total Joint ReplacementSurgery-Vascular
TransplantationUndersea & Hyperbaric MedicineUrogynecology
UrologyVascular NeurologyWound Care

Board Certifications

Board Certifications:

Please select your Board Certifications:

Addiction MedicineAddiction PsychiatryAdolescent Medicine
Allergy & ImmunologyAnesthesiologyBlood Banking/Transfusion Medicine
CardiologyCardiology-Adult Congenital Heart DiseaseCardiology-Advanced Heart Failure & Transplant
Cardiology-InterventionalClinical BioChemical GeneticsClinical Cardiac Electrophysiology
Clinical NeurophysiologyCritical Care MedicineCytopathology
Dentistry-EndodonticsDentistry-GeneralDentistry-Implant
Dentistry-Oral SurgeryDentistry-OrthodonticsDentistry-Periodontics
DermatologyDermatopathologyEmergency Medicine
Endocrinology-Diabetes & MetabolismEpilepsyFamily Medicine
GastroenterologyGeriatric MedicineGynecologic Oncology
GynecologyHematologyHematopathology
Hospice & Palliative MedicineInfectious DiseaseInternal Medicine
Maternal & Fetal MedicineMedical OncologyMedical Toxicology
Neonatal-Perinatal MedicineNephrologyNeurodevelopmental Disabilities
NeurologyNeuromuscular MedicineNeuropathology
Neurophysiology-ClinicalNeuroradiologyNuclear Medicine
Nuclear RadiologyOB/GYNOccupational Medicine
OphthalmologyOrthopedicsOtolaryngology/Ear-Nose-Throat
Pain MedicinePain Medicine-AnesthesiologyPathology
Pathology-Anatomical & ClinicalPathology-ChemicalPathology-Forensic
Pathology-Medical MicrobiologyPathology-Molecular GeneticPathology-Oral
Pediatric-CardiologyPediatric-Child AbusePediatric-Critical Care
Pediatric-DentistryPediatric-Developmental/BehavioralPediatric-Emergency Medicine
Pediatric-EndocrinologyPediatric-GastroenterologyPediatric-Hematology/Oncology
Pediatric-Infectious DiseasePediatric-NephrologyPediatric-Otolaryngology
Pediatric-PulmonologyPediatric-RadiologyPediatric-Rehabilitation Medicine
Pediatric-RheumatologyPediatricsPediatric-Surgery
Pediatric-UrologyPhysical Medicine & RehabilitationPodiatry
ProsthodonticsPsychiatryPsychiatry-Child & Adolescent
Psychiatry-GeriatricPsychosomatic MedicinePulmonary Disease
Radiation OncologyRadiology-DiagnosticRadiology-Interventional
Radiology-Vascular & InterventionalReproductive Endocrinology/InfertilityRheumatology
Sleep MedicineSpinal Cord Injury MedicineSports Medicine
Surgery-Colon & RectalSurgery-Critical CareSurgery-General
Surgery-HandSurgery-Head-Neck & Facial PlasticSurgery-Neurological
Surgery-OncologySurgery-Oral & MaxillofacialSurgery-Plastic
Surgery-Thoracic & CardiacSurgery-VascularUndersea & Hyperbaric Medicine
UrologyVascular 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, Philosophy of Care Statement and Clinical Interests

Biography, Philosophy of Care Statement and 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:

Form Verification Information

*Name of individual completing this form:

*Phone:

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

*Confirm Security Question below: