Provider Credentialing Application

PROVIDER CREDENTIALING APPLICATION

[ORGANIZATION NAME]
Credentialing Department
[ADDRESS]
[PHONE] | [FAX] | [EMAIL]

APPLICATION INSTRUCTIONS

Please complete all sections of this application. Type or print clearly in black ink. Attach additional sheets if necessary. Incomplete applications will delay processing.

Application Date: [DATE]

Application Type:
☐ Initial Credentialing
☐ Re-credentialing
☐ Add to Network
☐ Update Information

SECTION 1: PERSONAL INFORMATION

1.1 Legal Name

Last Name: [LAST NAME]

First Name: [FIRST NAME]

Middle Name: [MIDDLE NAME]

Suffix: [JR., SR., II, III, etc.]

Maiden Name / Other Names Used: [NAMES]

Professional Designation(s): [MD, DO, NP, PA, etc.]

1.2 Contact Information

Home Address:
[STREET ADDRESS]
[CITY, STATE ZIP]

Mailing Address (if different):
[STREET ADDRESS]
[CITY, STATE ZIP]

Home Phone: [PHONE]

Cell Phone: [PHONE]

Email: [EMAIL]

1.3 Demographics

Date of Birth: [DATE]

Place of Birth: [CITY, STATE/COUNTRY]

Social Security Number: [SSN]

Gender: ☐ Male ☐ Female ☐ Non-binary ☐ Prefer not to say

Languages Spoken: [LANGUAGES]

SECTION 2: PROFESSIONAL IDENTIFIERS

2.1 National Provider Identifier (NPI)

Individual NPI: [NPI NUMBER]

NPI Effective Date: [DATE]

2.2 Tax Information

Tax ID Number (TIN/EIN): [TIN]

☐ Individual ☐ Group/Organization

2.3 Other Identifiers

Medicare PTAN: [NUMBER]

Medicaid Provider ID: [NUMBER] State: [STATE]

UPIN (if applicable): [NUMBER]

CAQH Provider ID: [NUMBER]

SECTION 3: PRACTICE INFORMATION

3.1 Primary Practice Location

Practice/Group Name: [NAME]

Practice Type:
☐ Solo Practice
☐ Single Specialty Group
☐ Multi-Specialty Group
☐ Hospital-Based
☐ Federally Qualified Health Center (FQHC)
☐ Community Health Center
☐ Other: [SPECIFY]

Address:
[STREET ADDRESS]
[CITY, STATE ZIP]
County: [COUNTY]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

Website: [URL]

Office Hours:
| Day | Hours |
|-----|-------|
| Monday | [HOURS] |
| Tuesday | [HOURS] |
| Wednesday | [HOURS] |
| Thursday | [HOURS] |
| Friday | [HOURS] |
| Saturday | [HOURS] |
| Sunday | [HOURS] |

Accepting New Patients: ☐ Yes ☐ No

Age Groups Served:
☐ Pediatric (0-17)
☐ Adult (18-64)
☐ Geriatric (65+)

Accessibility:
☐ Wheelchair accessible
☐ Public transportation accessible
☐ Interpreter services available
☐ TTY/TDD available

3.2 Additional Practice Locations

[REPEAT ABOVE FOR EACH ADDITIONAL LOCATION]

SECTION 4: EDUCATION AND TRAINING

4.1 Professional School

School Name: [NAME]

Degree: [MD, DO, etc.]

Address: [CITY, STATE/COUNTRY]

Dates Attended: [START DATE] to [END DATE]

Graduation Date: [DATE]

ECFMG Certificate Number (if applicable): [NUMBER]

ECFMG Certificate Date: [DATE]

4.2 Internship

Institution: [NAME]

Address: [CITY, STATE]

Program Type: [TYPE]

Dates: [START DATE] to [END DATE]

Completed: ☐ Yes ☐ No

4.3 Residency

Institution: [NAME]

Address: [CITY, STATE]

Specialty: [SPECIALTY]

Dates: [START DATE] to [END DATE]

Completed: ☐ Yes ☐ No

Program Director: [NAME]

4.4 Fellowship (if applicable)

Institution: [NAME]

Address: [CITY, STATE]

Subspecialty: [SUBSPECIALTY]

Dates: [START DATE] to [END DATE]

Completed: ☐ Yes ☐ No

4.5 Other Training

[LIST ANY ADDITIONAL RELEVANT TRAINING]

SECTION 5: LICENSURE

5.1 Medical License(s)

5.2 DEA Registration

DEA Number: [NUMBER]

State: [STATE]

Expiration Date: [DATE]

Schedules: ☐ II ☐ II-N ☐ III ☐ III-N ☐ IV ☐ V

Additional DEA Registrations:
[LIST IF MULTIPLE]

5.3 State Controlled Substance License (if required)

State: [STATE]

License Number: [NUMBER]

Expiration Date: [DATE]

5.4 Other Licenses/Certifications

SECTION 6: BOARD CERTIFICATION

6.1 Primary Board Certification

Board Name: [BOARD NAME]

Specialty: [SPECIALTY]

Certification Date: [DATE]

Expiration/Recertification Date: [DATE]

Certificate Number: [NUMBER]

Status: ☐ Board Certified ☐ Board Eligible ☐ Not Applicable

If Board Eligible:
Expected Certification Date: [DATE]

6.2 Additional Board Certifications

SECTION 7: WORK HISTORY

List all professional positions for the past 5 years (most recent first):

Position 1 (Current)

Employer/Practice: [NAME]

Address: [ADDRESS]

Position/Title: [TITLE]

Dates: [START DATE] to Present

Supervisor/Contact: [NAME]

Phone: [PHONE]

Reason for Leaving: N/A (Current)

Position 2

Employer/Practice: [NAME]

Address: [ADDRESS]

Position/Title: [TITLE]

Dates: [START DATE] to [END DATE]

Supervisor/Contact: [NAME]

Phone: [PHONE]

Reason for Leaving: [REASON]

[CONTINUE FOR ALL POSITIONS IN PAST 5 YEARS]

Gaps in Employment

Explain any gaps in employment greater than 30 days:

SECTION 8: HOSPITAL AFFILIATIONS

8.1 Current Hospital Privileges

8.2 Previous Hospital Affiliations

8.3 Primary Admitting Hospital

Hospital Name: [NAME]

Address: [ADDRESS]

Phone: [PHONE]

SECTION 9: PROFESSIONAL LIABILITY INSURANCE

9.1 Current Coverage

Insurance Carrier: [CARRIER NAME]

Policy Number: [NUMBER]

Coverage Type: ☐ Claims-Made ☐ Occurrence

Effective Dates: [START DATE] to [END DATE]

Coverage Limits:

• Per Occurrence: $[AMOUNT]
• Aggregate: $[AMOUNT]

Retroactive Date (if claims-made): [DATE]

9.2 Previous Coverage (Past 5 Years)

SECTION 10: MALPRACTICE CLAIMS HISTORY

Have you ever had a malpractice claim filed against you?
☐ No
☐ Yes (complete below for each claim)

Claim 1

Date of Incident: [DATE]

Date Claim Filed: [DATE]

Plaintiff Name: [NAME]

Nature of Allegations: [DESCRIPTION]

Insurance Carrier: [CARRIER]

Status:
☐ Pending
☐ Settled - Amount: $[AMOUNT]
☐ Judgment for Plaintiff - Amount: $[AMOUNT]
☐ Judgment for Defendant
☐ Dismissed

Explain the circumstances:
[DETAILED EXPLANATION]

[CONTINUE FOR ALL CLAIMS]

SECTION 11: DISCLOSURE QUESTIONS

Please answer the following questions. If you answer "Yes" to any question, provide a detailed explanation on a separate sheet.

11.1 Licensure

☐ Yes ☐ No - Has your license to practice ever been denied, revoked, suspended, reduced, limited, placed on probation, or not renewed in any state?

☐ Yes ☐ No - Have you ever voluntarily surrendered a license?

☐ Yes ☐ No - Have you ever been subject to a consent order, formal reprimand, or other disciplinary action by any licensing board?

☐ Yes ☐ No - Is any action currently pending against your license?

11.2 DEA/Controlled Substances

☐ Yes ☐ No - Has your DEA registration or state controlled substance license ever been denied, revoked, suspended, limited, or placed on probation?

☐ Yes ☐ No - Have you ever voluntarily surrendered a DEA or controlled substance registration?

11.3 Hospital Privileges

☐ Yes ☐ No - Have your hospital privileges ever been denied, revoked, suspended, reduced, limited, placed on probation, or not renewed?

☐ Yes ☐ No - Have you ever voluntarily surrendered or relinquished hospital privileges?

☐ Yes ☐ No - Have you ever been subject to a focused professional practice evaluation (FPPE) or proctoring?

11.4 Medicare/Medicaid

☐ Yes ☐ No - Have you ever been excluded, suspended, or debarred from participation in Medicare, Medicaid, or any federal healthcare program?

☐ Yes ☐ No - Has your Medicare or Medicaid provider number ever been revoked or suspended?

☐ Yes ☐ No - Have you ever been sanctioned or fined by Medicare or Medicaid?

11.5 Professional Organizations

☐ Yes ☐ No - Have you ever been disciplined, expelled, or had membership denied by any professional organization?

11.6 Criminal History

☐ Yes ☐ No - Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?

☐ Yes ☐ No - Have you ever been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor related to healthcare, controlled substances, fraud, theft, or moral turpitude?

☐ Yes ☐ No - Are any criminal charges currently pending against you?

11.7 Other Actions

☐ Yes ☐ No - Have you ever been reported to the National Practitioner Data Bank (NPDB)?

☐ Yes ☐ No - Have you ever had your professional liability insurance cancelled, not renewed, or restricted?

☐ Yes ☐ No - Have you ever been investigated or disciplined by any employer?

☐ Yes ☐ No - Do you currently have any physical or mental condition that could affect your ability to practice safely?

☐ Yes ☐ No - Do you currently have any substance use disorder that could affect your ability to practice safely?

SECTION 12: REFERENCES

Provide three (3) professional references who can attest to your clinical competence:

Reference 1

Name: [NAME], [CREDENTIALS]

Specialty: [SPECIALTY]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Phone: [PHONE]

Email: [EMAIL]

Years Known: [NUMBER]

Reference 2

[SAME FORMAT]

Reference 3

[SAME FORMAT]

SECTION 13: ATTESTATION AND SIGNATURE

I certify that:

☐ All information provided in this application is true, correct, and complete to the best of my knowledge

☐ I have not knowingly withheld any information that might affect consideration of my application

☐ I authorize investigation of all information contained in this application

☐ I authorize all organizations, institutions, and individuals to release information regarding my professional qualifications, credentials, clinical competence, character, and ethical standing

☐ I agree to notify [ORGANIZATION NAME] within 30 days of any changes to the information provided

☐ I understand that falsification or misrepresentation may result in denial or termination of credentials

☐ I understand and agree to abide by the policies, procedures, and requirements of [ORGANIZATION NAME]

☐ I release [ORGANIZATION NAME] and all individuals providing information from any liability arising from this credentialing process

Applicant Signature: ______________________________________

Printed Name: [NAME]

Date: ______________

REQUIRED ATTACHMENTS

☐ Curriculum Vitae (CV)
☐ Copy of current medical license(s)
☐ Copy of DEA registration
☐ Copy of board certification(s)
☐ Copy of ECFMG certificate (if applicable)
☐ Copy of current professional liability insurance certificate
☐ Copy of hospital privilege letters
☐ Copy of government-issued photo ID
☐ Explanations for any "Yes" answers in Section 11

FOR OFFICE USE ONLY

Date Received: [DATE]

Received By: [NAME]

Application Complete: ☐ Yes ☐ No

Missing Items: [LIST]

Primary Source Verification Completed:
☐ License verification
☐ DEA verification
☐ Board certification verification
☐ Education verification
☐ NPDB query
☐ OIG/SAM exclusion check
☐ Malpractice history
☐ Work history verification

Credentialing Committee Review Date: [DATE]

Decision: ☐ Approved ☐ Denied ☐ Pending

Effective Date: [DATE]

Re-credentialing Due: [DATE]