Practitioner Data Entry

The first screen that presents for data entry is the Demographic information.

Field	Description	Example
Practitioner Type *	Practitioner type/specialty	Neuropsychologist (NEU)
Last Name *	Practitioner’s surname	Agbayani
First Name *	Practitioner’s given name	Chloe
Middle Name	Practitioner’s middle name	Grace
Prefix	Honorific prefix, for example: Dr., Mr., Mrs., Ms., Mx.	Ms.
Birth Date	Practitioner’s birthday in MM/DD/YY format	09/20/1986
SSN	Practitioner’s social security number	123-45-6789
NPI Practitioner	Practitioner’s National Practitioner Identification number	1467586115
Ethnicity	Practitioner’s ethnicity	Filipino
Citizen	This checkbox denotes if this practitioner is a citizen	☒
Citizen Country	The practitioner’s country of citizenship	United States
Birth Country	The practitioner’s country of birth	Philippines
Notes	Any notes pertaining to this practitioner

Fields noted with an asterisk (*) are required.

Enter the data requested and select the Save button to save your work.

Note Specific instructions for each panel may be noted below the panel label and Hover Text can be configured for specific field level information

Once the Demographics data is saved additional menus will become available for entry. Menus with an arrow next to the name have additional sub menus for data entry.

Menu	Description
Main	This is the main menu.
Practice	Practices where the practitioner has worked.
Licenses	Professional license that the practitioner holds
Appointment and Description	Hospital privileges that the practitioner holds/has held.
Education	The practitioner’s educational history.
Insurance	Insurance information.
Plans and Description	Payer Plan/Product information.
Images and Documents	Images and documentation associated with the practitioner.
Docs	Documents provided by the sponsoring association that must be downloaded, completed, and then re-uploaded to eApply.
Submit	Information review before submitting the application.

Screen-level Data Entry

All additional data entry panels function in the same manner. The following example uses the License menu to illustrate.

To create a new row of data:

Click the Create New button to open the data entry panel
Enter data ensuring all required fields are populated.
Save

If additional new data is needed for the same panel, repeat the steps above.

If edits are needed to the existing data clicking on the data hyperlink will open that panel for editing.

Navigate through the menu items and complete all applicable data entry.

Images

The Images panel functions similarly to other data entry panels.

Click the Create New button to open the data entry panel.
Select the appropriate value from the Document Type dropdown field.
Use the Browse button to navigate to the Image file you are uploading and select Open.
(Optional) To link the image to a record, click the link icon and select the appropriate record.
Save.

Repeat these steps to upload additional images need.

Documents

The Documents panel contains documents that the sponsoring organization needs the provider to download and complete and/or sign and then upload to eApply. This is currently only available for Practitioner records.

Click the Document Name hyperlink to open the panel.
Select the download icon next to the Document Name field to download a copy of the document to be completed and/or signed.
Once completed use the Browse button to navigate to the Image file you are uploading and select Open.
Save.

If additional documents need to be uploaded repeat the steps above.

Submitting the Application

Once all necessary data, images and documents have been entered and uploaded select the Submit button and you should see all required panels with a green check mark.

Note Users may enter data and add images or documents in multiple sessions if necessary. All updates are saved in between user sing-in sessions. Users may return to their application and update as necessary prior to final submission.

If any sections have been omitted, you will see a red X and this data must be completed before submission can occur. Click Submitting the Application, above, to return to the Document page to complete the missing information.

Incomplete Application Example

In the above example, Documents, Practitioner Licenses and Practitioner Work History is not complete. Therefore, this application is not ready to submit.

Complete Application Example

In the above example, all sections are recognized to be complete and marked with a green checkmark. Therefore, this application is ready to submit.

Once the application has been successfully submitted you will receive this message and have an opportunity to download a PDF copy of your submitted application data.

The sponsoring organization will be notified of your submission for processing.