Credentialing Application Form

Credentialing Application Form

Applicant Identifying Information

Applicant Name:

Date of Birth: / /

Phone:    Email:

Licensure and Professional Identifiers

Issuing State:    Expiration: / /

Education, Training, and Certification

Professional Experience

Hospital Privileges and Malpractice Insurance

Policy Number:    Limits of Liability:

Background, Disciplinary, and Legal Matters

Have you ever been denied a license, privileging, membership, or been subject to disciplinary action? Yes No

Have you had any malpractice claims, suits, settlements, or judgments in the past ten years? Yes No

References

Scope of Practice / Services

Attachments / Supporting Documents

Indicate documents attached (check all that apply): Curriculum Vitae License Copy Board Certificate Malpractice Declarations

Certification, Authorization, and Release

I certify that the information contained in this application and any supporting documents is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation, omission, or falsification of information may be grounds for denial, termination, or other corrective action by the credentialing entity.

I authorize the credentialing entity, its agents, and any third parties engaged by it to verify and investigate all statements and representations contained herein, including but not limited to primary source verification of licensure, education, training, board certification, malpractice claims history, and disciplinary actions. I authorize all individuals and organizations to furnish such information and release them from any liability for providing such information in good faith.

I acknowledge that submission of this application does not guarantee appointment, privileging, or reimbursement and that the credentialing entity may deny or limit privileges based on information discovered during the vetting process. I agree to promptly notify the credentialing entity in writing of any material changes to the information provided herein.

I understand that this application and any information obtained in connection with it will be retained in the credentialing entity's files and will be used for the purposes of credentialing, privileging, and related quality and compliance activities. I consent to such use and to disclosure of such information to contracted payors, oversight bodies, and peer review organizations as permitted by law.

Acknowledgment of Policy and Governing Law

This application shall be governed by the internal policies of the credentialing entity and applicable law. Any disputes arising from this application shall be resolved in accordance with applicable statutes and regulations governing credentialing and peer review activities.

Applicant Attestation

By signing below, I declare under penalty of perjury that the foregoing is true and correct. I understand that intentional falsification may constitute fraud and subject me to civil or criminal liability, as well as denial or revocation of privileges.

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