Application: Hyperbaric Medicine Provider

For PAs, NPs and physicians with a certificate of completion for the IBHBOT Introduction to Hyperbaric Medicine course.

Legal name (must match your photo ID)(Required)

Prefix First Last Suffix

Email(Required)

Phone(Required)

Mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Training site(Required)

Instructor name(Required)

Course completion date(Required)

License(Required)

License number(Required)

Issuing state or authority(Required)

License expiration date(Required)

Specialty or practice setting (optional)

Certificate of completion, Introduction to Hyperbaric Medicine(Required)

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.

Copy of current license(Required)

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.

Government-issued photo ID(Required)

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.

Testing accommodations requested (optional)