Healthcare Credentialing Request

HEALTHCARE CREDENTIALING REQUEST

Use this Healthcare Credentialing Request to initiate primary source verification and privileging/credentialing review. Complete all applicable sections and provide true, accurate, and complete information. Submission of incomplete or inaccurate information may delay processing or result in denial. By signing this form the applicant authorizes release of records and attests to the accuracy of the information provided, as further described in the Authorization and Attestation section below.

Provider Information

Date of Birth:    Gender: Male   Female   Other

Practice / Group Information

Professional Identifiers & Licensure

DEA Issue Date:    DEA Expiration Date:

Board Certified: Yes   No   If yes, Board Name: Year Certified:

Education, Training & Employment

Malpractice Insurance & Claims

Coverage Limits (Per Claim / Aggregate):    Tail Coverage in place: Yes   No

Have any malpractice claims been filed against you that resulted in payment or settlement? Yes   No

Hospital Privileges & Affiliations

Privileges currently active, suspended, revoked, or denied? Active   Suspended   Revoked   Denied

Professional References

Adverse Actions & Criminal History

Have you ever had a professional license disciplined, limited, suspended, revoked, or subjected to probation? Yes   No

Have you ever been excluded from participation in Medicare, Medicaid, or other federal health care programs? Yes   No

Have you ever been convicted of a felony or misdemeanor related to health care fraud, controlled substances, or patient care? Yes   No

Authorization & Attestation

I certify that the information provided in this Healthcare Credentialing Request and any attachments is true, accurate, and complete to the best of my knowledge. I understand that omission or misrepresentation of information may constitute cause for denial of credentialing, termination of affiliation, and may subject me to civil or criminal penalties under applicable law.

I authorize any hospital, medical school, residency or fellowship program, insurance carrier, employer, law enforcement agency, professional society, or other organization or person to release to the requesting organization any information, including but not limited to, credentials, records, performance data, complaints, investigatory materials, and disciplinary actions relevant to my professional qualifications and competence. I release such persons and entities from any liability for providing information in good faith.

I authorize the requesting organization to obtain primary source verification of my licensure, board certification, education, training, professional references, and malpractice coverage. I further consent to obtain background checks, including criminal history and sanctions checks, as required for credentialing purposes.

This authorization shall remain in effect for a period necessary to complete the credentialing process and any recredentialing reviews. Authorization expiration date: .

I acknowledge that the requesting organization may obtain and use protected health information (PHI) about me as necessary to evaluate credentialing application materials and that such PHI may be exchanged with peer reviewers and credentialing committees. I authorize release of PHI for these purposes.

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