Healthcare Credentialing Packet

HEALTHCARE CREDENTIALING PACKET

Purpose: This packet collects identifying, licensing, professional and legal information necessary to evaluate the applicant for participation and credentialing with payers, hospitals and affiliated entities. Completion of this packet and submission of required attachments authorizes verification of all statements and release of information to credentialing entities. False statements, omissions or misrepresentations may constitute grounds for denial, revocation or termination of privileges and may be cause for disciplinary action.

Provider Identification

Date of Birth:    Gender:    NPI Number:

Phone:    Email:

Professional Licensure and Controlled Substance Registrations

Complete all licenses held. Provide copies of current license documents with this packet.

State:   License #:   Status:

Issue Date:   Expiration Date:

State:   License #:   Status:

Issue Date:   Expiration Date:

DEA #:   Status:   Expiration Date:

Education, Training, Board Certification

Board:   Certification #:

Date Certified:   Status:

Hospital Affiliations and Privileges

Malpractice Insurance and Claims History

Policy Number:   Limits:   Coverage Type: Occurrence Claims-made

Retroactive Date (if claims-made):

Yes    No

Work History (Last 5 Years)

Professional References

Disclosure Questions (Answer all; attach explanations for any "Yes")

1. Have you ever been convicted of a felony or misdemeanor related to healthcare delivery? Yes No

2. Have you ever been subject to disciplinary action, investigation, or restriction by any licensing board or professional society? Yes No

3. Have you ever had clinical privileges denied, reduced, suspended, revoked or limited at any hospital or facility? Yes No

4. Have you ever had a final adverse finding or payment related to professional liability? Yes No

5. Are you currently excluded, suspended or debarred from participation in federal or state healthcare programs? Yes No

Attachments Checklist

Please attach the following documents. Check each item you are including.

Current curriculum vitae / resume
Copy of current state license(s)
Copy of DEA certificate (if applicable)
Malpractice declarations / policy face sheet
Board certification documentation (if applicable)
Government-issued photo identification
Other supporting documents (list below)

Authorization, Release, and Attestation

By signing below, I certify under penalty of perjury that the information provided in this packet and any attachments is true, correct and complete to the best of my knowledge. I understand that any material misrepresentation, omission or failure to disclose requested information may constitute cause for denial, suspension, limitation or revocation of credentials and may subject me to disciplinary action.

I authorize any hospital, medical school, training program, employer, professional liability carrier, licensing board, and other entities to release to the requesting organizations any information concerning my professional competence, conduct, education, training, credentials, malpractice history, and other relevant information. I hereby release all such persons and entities from liability for providing such information.

I further authorize the use of this signed credentialing packet, copies of it and information obtained from verification as part of the credentialing and recredentialing process. This authorization shall remain in effect until the later of the date indicated below as the authorization expiration date or one year from the date of signature, unless revoked in writing and submitted to the requesting organization; however, revocation will not affect disclosures already made in reliance on this authorization.

I acknowledge that I have received or been offered a copy of the applicable privacy practices and understand that information obtained in the credentialing process may be used and disclosed in accordance with such practices.

Initials:

Additional Certifications and Declarations

I affirm that I will notify the credentialing entity in writing within 30 days of any change in my license status, malpractice coverage, criminal history, hospital privileges, disciplinary actions, or any other material change that could affect my credentialing status.

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