Prior to working with MCN, we expect that all consultants complete a credentialing process. This includes providing copies of current state medical licensure, board certification (or residency completion for those who are “board eligible”), CV/resume, evidence of current malpractice coverage, a signed W-9, a signed electronic signature agreement, a completed and signed MCN physician/consultant agreement, and a completed and signed physician-consultant application. It is expected that consultants will maintain current status on licensure and malpractice coverage and forward documentation on an annual basis. It is also expected that MCN be notified immediately if there are any changes in the consultant’s licensure status or malpractice coverage, or other changes that alter the responses previously provided in the credentialing process.

The following documents will be necessary to complete the business relationship:

Consultant’s Application Checklist

Consultant agreement
Consultant application
Worker’s Compensation Application (if applicable)
Office Locations (if applicable)
W-9 completed and signed
Scheduling and Payment Agreement
Electronic Signature Form
Copy of your current CV/resume
Copy of current state medical licenses
Copy of board certification and fellowship training
Copy of current malpractice insurance

MCN uses a master database for primary-source verification to confirm Board Certification, current state licensure, residency information, medical school graduation and other information. If the physician has had any reportable matters to a licensing board or NPDB (National Practitioner Database), we will access the NPDB and state databases for details and determine on a case-by-case basis if you are an appropriate candidate for this type of work and inclusion in MCN’s physician network.

Credentialing Forms:

Click here to download the credentialing form