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Dastify Solutions

New Client Intake

Individual Provider Information Data Intake Form

Complete all sections below to begin the credentialing process. Your information is encrypted and stored securely.

HIPAA Compliant
256-bit Encryption

Individual Provider Information

Healthcare provider credentials and licensing

Provider Full Legal Name*

Individual NPI (Type 1)*

Provider SSN*

Provider Date of Birth*

Professional License Number*

DEA Registration Number

Board Certification

Email*

Professional Liability Insurance Carrier*