Consultant Information / Become A Consultant  
Step 1 of 3

Participating Reviewer Application
Applicant's Name:  
Mailing Address:
City State Zip
Fax Number:      
Cell Phone:

E-mail Address:
Office Locations:                 
Office Contact Person:

Tax ID # and Corporation Name (If Applicable):  
Tax ID

Include State, License Number
Expiration Date, Status (Active/Inactive)
State License # Expiration Status
Board Certifications:
If there are none please enter the word "none".
Specialty Year of Certification

Practice Focus:      
Current Level of Practice:
Number of hours/week  
Name of Malpractice Insurer:
Describe any license suspensions or limitations on
your license or activities.
If there are none please enter the word "none".

List any area of potential conflicts of interest:

Testifying Experience:
Worker Compensation
Civil Litigation
No Fault Arbitration

Days available to testify
Languages other than English:
Hospital affiliation(s) and staff status:
History of sanctions and disciplinary actions:
Professional References
(list two):
Percentage of  Practice:
What percentage of your practice is dedicated to independent reviews and examinations?
Stake-Holder: Are you personally a stake-holder in any Independent Review Organization, or any other such organization that performs services and duties similar to that of Crossland Medical Review Services Inc?

Please be sure to review your information for accuracy, as you will not be able to correct it once you click on the NEXT button. Please do not use the BACK button on your browser. Also, if multiple doctors are entering information from the same location, please close and re-open your browser before filling out the on-line form. Failing to due so will inhibit the information previously entered from being submitted. If you need to make a correction after you have already submitted your information, please contact Crossland Medical Review Services at 516-677-1114.