Credentialing Document

CREDENTIALING DOCUMENT

Parties

Recitals

WHEREAS, Organization operates a credentialing program to verify professional qualifications of individuals providing professional services under Organization's policies and payor contracts; and

WHEREAS, Applicant represents that Applicant holds and will maintain the qualifications, licensure, certifications, and insurance necessary to perform the services described herein; and

NOW, THEREFORE, in consideration of the mutual covenants contained in this Document, the parties agree as follows.

Definitions

For purposes of this Document, "Credentialing" means the process by which Organization verifies credentials, licensure, training, experience and background information necessary for participation with Organization and applicable payors.

Scope of Services

Applicant shall provide the professional services described below and shall comply with Organization policies applicable to credentialed providers.

Credentialing Data

License Number:    State of Issue:    Expiration Date:

NPI Number:    Specialty:

Credentials Checklist

Current license(s) — copy provided
Curriculum vitae
Malpractice history / claims disclosure
Board certification (if applicable)
Authorization for background and sanction checks

Representations, Warranties, and Authorization

Applicant represents and warrants that all information, statements, and documents submitted to Organization in connection with credentialing are true, complete, and not misleading. Applicant acknowledges that Organization may rely on such information in granting credentialed status and that any material misrepresentation is a basis for denial, suspension, or termination of credentialing.

Applicant authorizes Organization and its agents to verify all statements and credentials, to obtain primary source verification, and to contact prior employers, licensing boards, educational institutions, and other sources of professional information as reasonably necessary to evaluate Applicant's qualifications.

Payment Terms

As consideration for credentialing services and administrative processing, the parties agree to the following payment terms.

Term and Termination

This Document becomes effective on the Start Date and, unless earlier terminated in accordance with this section, will terminate on the End Date.

Start Date:    End Date:

Either party may terminate for material breach if the breaching party fails to cure within the stated notice period. Organization may suspend credentialing status immediately upon discovery of unverified or adverse information pending investigation.

Confidentiality

All non-public information exchanged in connection with credentialing, including but not limited to application materials, references, and investigation reports, shall be treated as confidential and used only for credentialing, quality assurance, and payor reporting purposes, except as required by law or authorized in writing. The receiving party shall take commercially reasonable steps to protect such information from unauthorized disclosure.

Insurance and Indemnification

Applicant shall maintain professional liability insurance in the minimum amount specified below and provide proof upon request. Applicant shall indemnify and hold Organization harmless from claims arising from Applicant's acts or omissions in the performance of services, except to the extent caused by Organization's gross negligence or willful misconduct.

Recredentialing

Applicant agrees to submit to periodic recredentialing at intervals required by Organization or applicable payors. Failure to cooperate with recredentialing may result in suspension or termination of credentialed status.

Governing Law

This Document shall be governed by and construed in accordance with the laws of the state specified below, without regard to conflicts of law principles.

Entire Agreement

This Document, together with any attachments and application materials incorporated by reference, constitutes the entire agreement between the parties concerning credentialing and supersedes all prior agreements and understandings, whether written or oral, relating to such subject matter. Any amendment or waiver must be in writing and signed by both parties.

Miscellaneous Provisions

If any provision of this Document is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. Notices required by this Document shall be in writing and delivered to the addresses set forth above or such other address as either party designates in writing.

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