Medical Director
Medical Director Coverage Preparation Worksheet
A structured worksheet to help licensed medical providers prepare information before requesting medical director coverage. This worksheet is educational — it is not a lead form and does not submit data. Use it to organize your information before a coverage conversation.
Last reviewed: 2026-08-04
Provider Information
- Provider license type (RN, NP, PA, MD/DO, other)
- State of licensure
- License number and expiration date
- Years of clinical experience
- Aesthetics experience (if any)
Practice Information
- Practice name (if established)
- Practice state
- Practice city or region
- Practice ownership structure (sole proprietor, LLC, professional entity, MSO)
- Fixed-site, mobile, or both
Services Offered
- List of treatments you plan to offer
- Whether treatments involve prescription products
- Whether treatments involve delegated clinical acts
- Whether prescribing is involved
- Estimated patient volume per week
Current Oversight (if any)
- Current medical director (if any)
- Current supervising physician (if any)
- Current collaboration agreement (if any)
- Reason for seeking new or additional coverage
Good Faith Exam Workflow
- Whether a Good Faith Exam is required in your state
- Who currently performs the exam (if anyone)
- How the exam is documented
- Whether telehealth exams are permitted in your state
Current Protocols
- Whether written treatment protocols are in place
- Whether emergency response protocols are in place
- Whether chart review is currently performed and how often
Current Systems
- Current EMR or documentation system
- Current consent form templates
- Current before-and-after photo protocols
- Current lot tracking system
Current Insurance
- Professional liability (malpractice) insurance carrier and coverage
- General business liability insurance
- Workers' compensation (if applicable)
Current Providers
- Number of providers who will be delegated
- License types of delegated providers
- Whether providers have aesthetic experience
Expansion Plans
- Plans to expand into additional states
- Plans to add new providers
- Plans to add new treatments or services
- Timeline for expansion
Questions for a Coverage Provider
- What is your availability for consultation and emergencies?
- How often do you perform chart review?
- What is your experience with the treatments I plan to offer?
- What does your medical director agreement typically include?
- How do you handle protocol development and updates?
- What are your fees and what do they cover?
Your Next Step
Ready to take the next step?
Use this checklist alongside the relevant NOVI support options. Requirements vary by state, license and practice structure — confirm specifics with qualified guidance.
NOVI resources are provided for general educational purposes and are not legal, medical, tax, financial, licensing, or regulatory advice. Requirements may vary by state, provider credentials, practice structure, and services offered. Current requirements should be confirmed with qualified professionals and official regulatory sources.