Apply For TBI Certification (Physicians)

First Name *

Last Name *

Email *

Phone *

What Type of Physician? (MD, DO, DC, DP OD, AP, PT or other) *

Specialty *

Tax ID Number *

If part of a group, please list group.

How long have you been in practice? *

How many malpractice law suits have you had? *

Any active law suits personal or business current or past 5 years? *

Yes

Have you been or ever in SIU by any insurance companies special investigation unit? *

Yes

Have you ever been convicted of misdemeanor, felony or DUI? *

Yes

If "Yes", please provide any relevant information or explanation.

Application Fee $300