Pre-Application Form

The NVA pre-application process is used to determine if a doctor meets criteria to apply to NVA. Completed pre-application information is reviewed by the NVA Credentialing Committee. In general, only practitioners who answer “Yes” to each of the pre-application questions shall be eligible to apply. If you answer “No” to a question, the NVA Credentialing Committee will consider the information you provide in explanation of the “No” answer and will determine whether your answer provides a compelling reason to grant an exception.

The cost to submit a pre-application is $50. This amount is not refundable. Pre-applications received without payment or incomplete pre-applications shall be returned.

After completing its review, NVA will notify you if you are eligible to submit a full application. You then have sixty (60) days to submit a full application. After sixty (60) days your eligibility will expire and NVA will close your application file.

Respond to each item below. If you answer “NO” to a question or if an explanation of your answer is needed to ensure completeness, please explain why.

If you do not want to pay by credit card, please download our paper pre-application and mail the pre-application and a check for $50 to the address:

P.O. Box 420
Cottage Grove, OR, 97424