Yes - The provider will be substituting for absent physician. Note: Q-6 billing permits services to be billed under the absent physician's NPI for a maximum of 60 consecutive days.

No - The provider will be billed under their own NPI once credentialing and payer enrollment are complete.

*Staffing Agency:

*Email Address:

Use of Locum Tenens is only appropriate in select circumstances when a physician, APP, or hospital must retain a substitute provider to assume professional practice during an absence for reasons such as illness, pregnancy, vacation, continuing medical education, or spikes in patient demand.

*Name of Absent Provider:

*Please describe specific need for Locum Tenens provider:

*First Name

Middle Name

*Last Name

*Degree (MD/DO/NP/PA, etc.)

DOB (MM/DD/YYYY)

If APP, Provide Supervising Physician

*Mobile Phone Number

*Email Address

*WV Medical License Number

*NPI Number

*Specialty

Additional Contact Name

Additional Contact Phone Number

Additional Contact Email

*Select only those facilities at which you plan to exercise privileges.

Mon Health Medical Center

Mon Health Marion Neighborhood Hospital

Mon Health Preston Memorial Hospital

Mon Health Stonewall Jackson Memorial Hospital

Davis Medical Center

Webster Memorial Hospital

Broaddus Hospital

*Enter Code Displayed (Security)

Locum Tenens Physician or APP

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