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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	Active Care (Workers' Comp)
Aetna	Aetna Better Health
Aetna Health Plans of NJ	Aetna Medicare
Aetna Medicare NNJ Prime	America’s Health Plan
Amerigroup (managed Medicaid plan)	AmeriHealth
Anthem Health	Beacon
BeechStreet PPO	Blue Cross/Blue Shield NJ
Braven Health	Centivo
Charity Care Accepted	CHN
Cigna	Cigna Behavioral Health
Cigna Health Springs	Cigna Healthcare/Great West
Cigna Medicare	Clover
Community Care Network	Consumer Health Plan
Coventry	Devon Health Services
DOL	Emblem
Emblem Health/GHI	Emblem Health/QualCare
Empire BCBS	Empire Health Choice
Empire through Blue Card Program	Evolutions Health Systems
Fidelis (WellCare)	First Health Network
First Managed Care Option	First MCO (Workers' Comp)
Galaxy Health Care	GHI
GHI PPO	GHI through Qualcare (Only for patients where the Qualcare logo appears on the ID card)
Great-West (Cigna)	Health New Federal Services
Health Republic Insurance of NJ	HealthNet Federal Health Services (TriCare-Champus)
HIP PPO	Horizon
Horizon BCBS	Horizon BCBS HMO
Horizon BCBS Indemnity	Horizon BCBS Medicare Blue
Horizon BCBS Omnia	Horizon BCBS PPO
Horizon Casualty	Horizon Casualty Services (Workers Comp & No Fault)
Horizon NJ Health	Horizon NJ Health (managed Medicaid plan)
Humana Medicare	Humana Tricare
Independence BCBS	Intergroup Services Corp
Longevity	Magellan Behavioral Health (B)
Magnacare	Managed Health Network (B)
MCS Patient Centered Health Care Network	Medicaid
Medicare	Multiplan
Multiplan/ PHCS	Multiplan/Beechstreet/PHCS/Viant
National Health Plan	National Preferred Provider Network (NPPN)/Planned Care America
National Provider Network	New Jersey Carpenters Health Fund (B)
New Jersey Manufacturers through Horizon Casualty	No Insurance Accepted
Northwell	Optum Behavioral Health
Oxford	Oxford Health
Oxford Health HMO	Oxford Health PPO
Oxford Medicare Advantage Plans	Oxford Medicare Advantage Private Fee For Service Plans (PFFS)
Private Health Care Systems (PHCS)	QualCare
QualCare Workers Comp	Railroad Medicare
Tricare	UHC/OX
UHCCP	United Behavioral (B)
United Community	United Healthcare
United Healthcare Community Plan (formerly Americhoice Managed Medicaid)	United Medicare Advantage Plans
United Medicare Advantage Private Fee For Service Plans (PFFS)	US Family Health Plan
US Family Health Plan (Tricare Prime)	US Family Plan
Value Options (B)	Wellcare
Wellcare Managed Medicaid (Family Care)	Wellcare Managed Medicare
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: