New Clinical Provider Submission Form

Requests to ADD NEW CLINICAL PROVIDERS are to be completed and submitted ONLY by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates.  The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes and does not meet participants’ independent credentialing or other required hiring background, screening, and/or onboarding processes.

If you need to add more than 10 new providers, STOP .. please do not use this process; rather, call your SIP Insurance Services team directly at the following phone # for assistance: 352-273-7006, or 844- MY FL SIP.


* below indicates a required field


(e.g., COM Radiology, CON, Student Health Services, etc.)


Please refer to the FMMJUA Specialty Descriptions included above.
Example: ME, DO, APRN
Full license # including prefix, (e.g. ME012345)
Examples: College of Medicine, Student Health Services, or Shands.
Percentage of provider’s employment/appointment, populated based on a 40 hour work week, converted into a decimal (e.g., 50% is .50).
Percentage of provider’s employment/appointment dedicated to clinical services, populated based on a 40 hour work week, converted into a decimal (e.g., if the provider is part time employment at .50 and she/he spends all of her/his employment delivering clinical services, the provider’s clinical FTE % should be .50 as well).
The delivery of professional healthcare services to patients located outside of the state of Florida.
The practice of health care delivery by a practitioner who is located at a site other than the site where a recipient is located for the purposes of evaluation, diagnosis, or treatment.

Provider Practice Sites

Click or drag files to this area to upload. You can upload up to 10 files.