Healthcare Credentialing Requirements

HEALTHCARE CREDENTIALING REQUIREMENTS

Purpose: This form documents the information and attestations required to initiate or renew credentialing with the medical group or health system. Completion and signature authorize verification of credentials, privileging, licensure, insurance, and any other records necessary to evaluate professional qualifications. Furnish complete and accurate information; omissions or falsifications may result in denial or revocation of privileges.

Provider Identification

Provider Name:

Contact / Practice Information

Licensure and Registrations

State License (Primary): State: License No.: Issue Date: Expiration Date:

License Status: Active Expired Restricted/Suspended

DEA Registration Number: Issue Date: Expiration Date:

Board Certification & Education

Hospital Privileges & Work History

Malpractice Insurance & Claims History

Any malpractice claims or settlements in the past 10 years? Yes No

Required Documents Checklist

Submit the following current documents with this application. Check each item to indicate it is attached.

Current state professional license (copy)

Current DEA certificate (copy)

Curriculum vitae (CV)

Board certification (if applicable)

Current malpractice insurance certificate (declaration page)

Government-issued photo ID (copy)

Current hospital privileges/letter of good standing

Background check release (if required)

Disclosure / Adverse Actions

Has your license, certification, DEA registration or hospital privileges ever been denied, restricted, reduced, suspended, revoked, investigated, or placed on probation? Yes No

Have you ever been convicted of a felony, pled guilty or nolo contendere to a felony, or are there any pending criminal charges? Yes No

Attestation and Authorization

By signing below, I certify under penalty of perjury that the information provided on this form and any attached documentation is true, complete, and correct to the best of my knowledge. I understand that deliberate omission or falsification of information may result in denial, suspension, or termination of credentialing or privileges.

I authorize the release of any information concerning my professional competence, conduct, education, training, and malpractice history to the requesting medical group, hospital, or payer for the purpose of evaluation, credentialing, recredentialing, or participation in payer networks. I expressly authorize entities holding such information to provide it upon request. I release all persons and entities from liability for furnishing such information.

This authorization is valid for the duration necessary to complete the credentialing process and remains in effect until revoked in writing. Authorization Expiration Date:

HIPAA / Privacy Acknowledgment

I acknowledge that the information provided may include protected health information (PHI) and that the reviewing entities will handle such information in accordance with applicable privacy laws and professional standards. I consent to release necessary PHI for credentialing and privileging purposes and understand that further disclosure will be governed by applicable law.

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