Licensing & Credentials Worksheet

Instructions: Use this worksheet to compile all your professional licenses, certifications, and insurance information before completing the Remote Medical Director onboarding form. Gather your license cards, certificates, and insurance documents, then fill in each row below.

Licenses & Certifications

License / Cert Type	License Number	State	Issue Date	Expiration Date	Status
Esthetician License
Cosmetology License
Nursing License (RN/LPN)
NP / PA License
Laser Safety Officer Certificate
Laser Technician Certification
BLS / CPR Certification
Liability Insurance Policy
Business License
State Facility License
DEA Registration (if applicable)

Insurance Details

Insurance Carrier

Policy Number

Coverage Amount

Expiration Date

Workers Compensation Carrier (if applicable)

Policy Number

Expiration Date

Additional Notes