Healthcare Credentialing Addendum

HEALTHCARE CREDENTIALING ADDENDUM

This Healthcare Credentialing Addendum supplements and becomes part of the credentialing application or file for the Provider identified below. It is submitted to update, clarify or add information necessary for verification of qualifications, privileging, and payer enrollment. Provider must complete all applicable sections and sign the attestation at the end.

Provider Identifying Information

NPI:    Primary Specialty:

Office Phone:    Email:

Provider Type

Individual Group/Corporation Clinic/Facility

Licensure and Certifications

State Medical License(s) (list all states, numbers and expiration dates). If additional space is required, attach separate signed page.

Hospital Privileges and Affiliations

List current hospital privileges or affiliations. Include hospital name, city/state, specialty privileges, status (Active/Requested/Suspended), and effective/termination dates.

Malpractice Insurance and Claims

Policy Number:    Coverage Dates:

Have there been any malpractice claims, settlements, judgments, or pending suits against you?   Yes No

Disciplinary, Licensure or Payment Sanctions

Within the past ten (10) years, have you ever been investigated, sanctioned, disciplined, excluded, or had restrictions placed on your clinical privileges, licensure, Medicare/Medicaid participation, or payer panels?   Yes No

Payer Enrollment / Panel Membership

Are you requesting the following changes or additions? Check all that apply.

Medicare Enrollment Medicaid Enrollment Add/Update Private Payers

Additional Practice Locations

Provide any additional practice locations for credentialing and site inspection purposes. Include address, phone, and effective dates.

Supporting Documentation Checklist

Indicate which updated documents accompany this addendum:

Updated Curriculum Vitae
Current State License(s)
Malpractice Declarations / Policy Page
Hospital Privilege Letters
Board Certification Documentation

Attestation and Authorization

By signing below, I certify under penalty of perjury that all information provided on this Addendum and any attachments is true, accurate and complete to the best of my knowledge. I understand that omissions, misrepresentations or falsifications may constitute grounds for denial or termination of participation in payer networks and may be reported to licensing boards and other entities.

I authorize any hospital, physician, medical facility, malpractice carrier, licensing board, law enforcement agency, payer, or other entity to release to the requesting health plan, credentialing entity, or its agents any information regarding my professional qualifications, credentials, and competence, including but not limited to malpractice history, disciplinary actions, and privileging records. I further authorize the release of such information for the purpose of credentialing, privileging, peer review, and payment enrollment. This authorization remains in effect until the Authorization Expiration Date indicated below or until revoked in writing.

Authorization Expiration Date:

I agree to report any material changes to the information provided in this Addendum (including changes in licensure, malpractice actions, hospital privileges, sanctions or exclusions) to the credentialing entity within thirty (30) days of occurrence.

Additional Statements

Sign Now