Healthcare Affiliation Form

HEALTHCARE AFFILIATION FORM

This Healthcare Affiliation Form is submitted by the applicant to request credentialing and affiliation with the facility or network identified by the receiving organization. Completion of this form authorizes the receiving organization to verify credentials, query professional databases, and obtain relevant records for the purpose of determining eligibility for privileges, enrollment, or participation. Inaccurate, incomplete, or omitted information may delay processing or result in denial of affiliation.

Applicant Information

Applicant Name:

Practice / Organization

Licensure and Board Certification

Primary State Medical License: Number State Expiration

Additional Licenses / States:

Education, Training, and Professional Background

Hospital Privileges and Practice Status

Professional Liability Insurance

Disciplinary Actions, Sanctions, and Exclusions

Have you ever been subject to disciplinary action, investigation, license revocation, surrender, or restriction by any licensing board, health plan, or hospital? Yes No

Professional References

Authorization, Attestation, and Release

I, the undersigned applicant, hereby certify that all information provided in this Healthcare Affiliation Form and any attachments is true, complete, and accurate to the best of my knowledge. I understand that falsification, omission, or misrepresentation of material information may result in denial, suspension, or termination of privileges or affiliation. I agree to provide supporting documentation upon request.

I authorize any person, institution, organization, or licensing board to release to the receiving organization any information, files, or records requested as part of the credentialing and verification process. I also authorize the receiving organization to conduct primary source verifications, query national practitioner databases, and obtain malpractice, disciplinary, and other relevant records.

I understand that this authorization will remain in effect for the duration of my application and for purposes of reappointment or ongoing credentialing reviews unless revoked in writing. Authorization expiration date (optional):

I agree to notify the receiving organization in writing within 30 days of any change in the information provided on this form, including changes in licensure status, malpractice claims, or disciplinary actions.

Acknowledgment of Privacy and Record Use

By signing below, I acknowledge that the receiving organization will maintain records of this application and related documentation in accordance with applicable privacy and record retention policies. I understand that information obtained for credentialing purposes may be disclosed to third-party payors, peer review organizations, and oversight entities as required by law or regulation.

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