Healthcare Credential Form

HEALTHCARE CREDENTIAL FORM

Provider Identification

Provider Name:

Date of Birth: Gender:

Licensure and Certification

State Medical License(s) (list state, license number, issue date, expiration date). Enter multiple on separate lines:

Education and Training

Practice Locations

Effective date at this location:     Accepting new patients: Yes No

Hospital Affiliations and Privileges

Professional Liability Insurance

Policy Number: Limits (per claim/aggregate):

Policy Type: Policy Expiration:

Professional History / Background Questions

For each question below, check Yes if applicable. If Yes, explain in the corresponding explanation field. A "Yes" response does not necessarily preclude credentialing but requires documentation.

1) Have you ever had disciplinary action, reprimand, or investigation by any licensing board or professional association?   Yes   No

2) Have you ever been convicted of a felony or misdemeanor related to professional practice?   Yes   No

3) Have you ever been subject to a malpractice claim, judgment, or settlement?   Yes   No

4) Have you ever been excluded, suspended or sanctioned by any federal or state health care program (e.g., medicare/medicaid)?   Yes   No

Professional References

Provide three professional references with current contact information.

Authorization, Attestation, and Release

I hereby certify that the information provided in this Healthcare Credential Form is true, complete and correct to the best of my knowledge. I understand that omission, falsification or misrepresentation of information may be grounds for denial, revocation or termination of affiliation and may subject me to disciplinary action.

I authorize all persons, institutions, licensing boards, employers, insurers and third parties to release to the requesting credentialing entity and its agents any information, records or documents necessary to verify the information supplied herein, including primary-source verification of education, training, licensure, board certification, malpractice history, and disciplinary records. I release such persons and entities from any liability for furnishing such information in good faith.

I understand that this authorization is valid for credentialing, reappointment, peer review and quality assessment activities. This authorization shall expire on the Authorization Expiration Date provided below unless earlier revoked in writing by me.

Privacy Acknowledgment: I acknowledge that the credentialing entity may obtain and use certain protected health information and other personal information about me for the limited purpose of credentialing and privileging. I consent to such use and disclosure to the extent reasonably necessary to verify credentials and evaluate qualifications.

I acknowledge and consent to the terms, attestations, and authorizations above.

Attachments

Please attach copies of: current state license(s), board certification, malpractice declarations page, DEA/state CDS registration, curriculum vitae, and any relevant disciplinary documentation. Indicate attached items below.

Current CV:   License copies:   Malpractice declarations:

Sign Now