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Initial Checklist

Before you begin please make sure you have saved copies of the following onto your computer or device:

 

 

  • Driver’s license
  • Birth Certificate or Passport if not born in US
  • Master’s degree
  • Professional license
  • Liability insurance
  • Documentation for any legal name change (i.e. Marriage License, etc)

    National Provider Identifier #

    If you do not have one yet, it is fairly simple to apply for one by selecting:
    "Apply for an NPI for Myself" on this website: nppes.cms.hhs.gov
    If you need assistance getting your NPI, please contact their Help Desk at (866)484-8049

    General Info
    Birth Info
    Professional License
    Emergency Contact
    Graduate School
    History
    Have you ever elected to be a “Non Participating” Medicare Provider?
    YesNo
    Have you been the subject of a civil or criminal complaint?
    YesNo
    Have you ever been investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?
    YesNo
    Have had any drug issues, convictions, etc?.
    YesNo
    Have you been examined by a certifying board but failed to pass?
    YesNo
    Have any disciplinary actions or proceedings been instituted against you?
    YesNo
    Required Documents
    Copy of driver's license*

    (Max: 4MB)
    Birth Certificate or Passport* (*ONLY IF BORN OUTSIDE THE USA)

    (Max: 4MB)
    Copy of Master's Degree*

    (Max: 4MB)
    Copy of Professional License from each state*

    (Max: 4MB)
    Copy of liability insurance (optional)

    (Max: 4MB)
    Documentation for any legal name change (i.e. Marriage License, etc) (optional)

    (Max: 4MB)

    You will receive an email from I&A NPPES system (CMS.GOV) separately with instructions to approve our Surrogate Request to submit your Medicare Application for a Medicare ID as a Blue Moon Therapist. If you do not already have a log in you will need to create one so you can enter the portal to approve the surrogacy requests so we may move forward on your application.

    GET STARTED