Healthcare CAQH Form

HEALTHCARE CAQH PROVIDER CREDENTIALING APPLICATION

Provider Name:   NPI:

DEMOGRAPHIC INFORMATION

Full Legal Name:

Date of Birth: Month Day Year

Male    Female    Other / Prefer not to disclose

PROFESSIONAL IDENTIFICATION

HOSPITAL AFFILIATIONS / PRIVILEGES

PROFESSIONAL LIABILITY INSURANCE / CLAIMS

Has the provider had any malpractice claims, suits, settlements or judgments in the last ten years?    Yes    No

CREDENTIALING / PRACTICE HISTORY

Has the provider ever been sanctioned, excluded, or subject to disciplinary action by any licensing board, payer, or government program?    Yes    No

PRACTICE / BILLING CONTACTS

Are you currently enrolled in Medicare or Medicaid?    Medicare    Medicaid

ADDITIONAL INFORMATION

Yes    No

ATTESTATION, AUTHORIZATION, AND RELEASE

By signing below, I certify that the information provided in this CAQH credentialing application is true, complete and correct to the best of my knowledge. I understand that any material misstatement, omission or falsification may constitute cause for denial, termination of participation or other corrective action by payers or credentialing entities.

I authorize any person, institution, organization or government agency to release to credentialing organizations, payers and their agents any information relevant to my professional credentials, licensure, malpractice history, employment history, and suitability for participation in health plans. I understand this authorization permits release of protected health information and other personally identifiable information as necessary to verify information in this application.

I agree to promptly notify credentialing entities of any change in the information contained herein, including but not limited to changes in licensure, malpractice coverage, hospital privileges, or any adverse actions within thirty (30) days of such change. This authorization for release shall expire on the date indicated below unless earlier revoked in writing.

By checking the box below I acknowledge that I have read and accept that credentialing organizations and payers may obtain and use protected health information and other personal information necessary to perform credentialing and enrollment verifications.    Acknowledged

VERIFICATION CONSENT

I consent to release and verification of education, training, licensure, certification, work history, malpractice history, and hospital privileges as part of credentialing and recredentialing processes. I understand that photocopies or electronic facsimiles of this document shall be valid as originals for the purposes of verification.

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