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Doctor Information Form Template

Streamline Your Data Collection with Our Doctor Information Form

Are you struggling to collect vital information from medical professionals? Our Doctor Information Form template helps healthcare organizations streamline the process of gathering contact and health details. Whether you need to onboard new doctors, update records, or ensure compliance, this template is designed for your needs, user-friendly and no coding required. It offers customizable fields, secure data collection, and is compliant with medical standards like HIPAA. Experience the ease of gathering essential insights by trying out the live template today.

Use this Template (FREE) Live Preview
Full name
Professional degree
Please Specify:
Primary specialty
National Provider Identifier (NPI)
Years in practice
0-2 years
3-5 years
6-10 years
11-20 years
21+ years
Prefer not to say
Medical license number
Licensing state(s) or country
License expiration date
Board certifications (list board and status)
Active malpractice insurance
Yes
No
Practice or clinic name
Primary practice address
Office phone
Office email
Preferred contact method
Phone
Email
Either
Visit types offered
In-person visits
Telehealth video
Telephone visits
Home visits
Procedures
Group sessions
Accepting new patients
Yes
No
Patient age groups served
Pediatrics (0-17)
Adults (18-64)
Geriatrics (65+)
All ages
Languages spoken in practice
Please Specify:
Insurances accepted (list plans or networks)
Self-pay accepted
Yes
No
I consent to publish my profile information on the organization website and directories
Yes
No
Type your full name as signature
Signature date
I attest that the information provided is accurate to the best of my knowledge
Yes
No
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Paper art illustration depicting a doctor information form template with various fields and sections for patient details

When to use this form

Use this template when you need accurate provider details for referrals, directories, on-call rotations, or vendor onboarding. Clinics, hospitals, telehealth teams, and school health programs benefit by capturing credentials, specialties, locations, and coverage hours in one place. It is also useful when you are matching patients to the right clinician or verifying insurance participation. Pair it with the New patient registration form to route patients to available providers, and with the Health questionnaire form to flag conditions that require a specific specialty. Rehab teams can connect it to the Physical therapist evaluation form to streamline handoffs. The result: fewer back-and-forth emails, faster scheduling, and a reliable source of truth for your care team.

Must Ask Doctor Information Questions

  1. What is your full legal name, credentials, and NPI number?

    This verifies identity and prevents duplicate provider records. It also supports insurance checks and clean claims.

  2. What is your primary specialty, practice name, and office address?

    This helps patients and staff find the right clinician at the right location. When paired with the New patient information form, you can route cases to the best-fitting provider.

  3. What phone number, email, and preferred contact method should we use?

    Clear contact data speeds referrals and reduces missed messages. Stating a preference sets expectations for response time.

  4. Which insurance networks do you accept, and are you accepting new patients?

    Knowing coverage avoids surprise billing and mismatched referrals. It also lets scheduling offer alternatives when a plan is out of network.

  5. List your licenses, certifications, DEA (if applicable), and expiration dates.

    This supports compliance audits and controlled substance rules. You can measure follow-up quality later with the Patient satisfaction survey form.

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