Are you updating/confirming an existing entry or is this a new application?
Please select...
This is a new application
Updating/confirming an existing entry and I know my application ID.
Updating/confirming an existing entry but I don't know my application ID.
Application ID
If you do not know your ID (EPF-####) please reach out to NEA via telephone at
800-818-7546
.
Is the provider listed no longer at your practice or is all of the listed
information correct and up to date?
Please select...
No
The provider listed is no longer at this practice
The listed information is correct and up to date
Person filling out the this form
First Name
Last Name
Title
Email Address
Do not enter a role-based email addresses such
as admin@, info@, office@, etc
.
Physician Details
First Name
Last Name
Suffix
Example: Jr, Sr, or II
Email Adress
Do not enter a role-based email addresses
such as admin@, info@, office@, etc.
Professional Credentials
Example: MD, DO or Board
Certifications.
Gender
Please select...
Female
Male
Other
Decline to answer
On average, how many patients with eczema
does this provider see per week?
Please select...
N/A
1 to 5
6 to 10
11 to 15
More than 15
Specialty (Select all that apply)
Allergy/Immunology
Dermatology
Internal Medicine
Family Medicine
Mental Health
Naturopathy
Pediatrics
Pediatric Dermatology
Pediatric Allergy/Immunology
Other
Please specify other specialty.
It looks like you indicated that you that you provide mental health services,
please indicate what type below. Select all that apply.
Biofeedback
Cognitive Behavioral Therapy
Group Therapy
Psychoanalysis
Do you conduct research in your practice or in another research setting?
Please select all that apply.
Clinical Trials
Other Clinical Research
Outcomes Research
Basic/Translational Research
Not Conducting Research
If you would like to have your professional photo displayed with your listing on the
Eczema Provider Finder, please upload a jpge/jpg file that is 500 px by 500px here.
Calculated Field - Type
Calculated Field - Provider
Practice Details
Name of Practice
Does your practice have a website?
Please select...
Yes
No
I can provide both a practice website and a professional online profile.
If your practice does not have a website you will have to enter
a link to your personal professional profile.
Practice Website URL
Personal Professional Profile
Address (include suite/office #)
Practice State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Practice City
Practice Zip Code
Practice Phone Number
Format: ###-###-####
Practice Email Address
Language
Languages (Select all that apply).
Arabic
Chinese (Cantonese)
Chinese (Mandarin)
English
French
German
Italian
Japanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Other
Other, please specify
Treatments Offered
Allergy Testing
In Office
By Referral
Allergy Immunotherapy
In Office
By Referral
Biologics
In Office
By Referral
Immunomodulators (oral & injectable)
In Office
By Referral
Phototherapy
In Office
By Referral
Systemics
In Office
By Referral
Topicals
In Office
By Referral
Complementary and Alternative
In Office
By Referral
Other, please specify
Accepted Payment Methods
What type of payment methods do you accept?
Please select all that apply.
Cash / Credit
Medicaid or equivalent
Medicare
Private Insurance
Sliding Scale
I understand that I will be required to verify the information on this application yearly and failure
to confirm these details will result in the removal of my listing from the Eczema Provider Finder.
Yes
No
I understand if anything on this application changes before my yearly verification,
I will need to inform the National Eczema Association of the changes
Yes
No
Click submit to confirm that the provider is longer at your practice.
Please allow 2-3 business days for the provider's entry to be
removed from NEA's Eczema Provider Finder.
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Contact Information