Healthcare Credentialing Template

HEALTHCARE CREDENTIALING APPLICATION

Provider Name:   Preferred Name/DBA:

National Provider Identifier (NPI):   Tax ID/EIN:

Contact and Practice Information

Hospital-based    Private practice    Clinic/FQHC    Other (specify):

Professional Identifiers & Licensure

State:    License Number:    Issue Date:    Expiration Date:

DEA Number:    State(s) Registered:    Expiration Date:

Education, Training & Hospital Affiliations

Graduation Year:    Residency/Fellowship:

Professional Liability Insurance

Policy Number:    Limits of Liability:    Retroactive Date:

Tail Coverage Available: Yes    No

Employment / Work History (Last 10 Years)

From:    To:    Reason for Leaving:

From:    To:    Reason for Leaving:

Professional References

Disclosure Questions

1. Has your license ever been denied, suspended, revoked, restricted, or voluntarily surrendered?   Yes   No

2. Have you ever been subject to disciplinary action by a hospital, professional society, state licensing board, federal agency, or payer?   Yes   No

3. Have you been convicted of a felony or convicted of a misdemeanor related to health care?   Yes   No

4. Have you had malpractice claims, settlements, or judgments against you in the last 10 years?   Yes   No

Authorization and Attestation

By signing below, I certify that the information contained in this application is true, complete, and correct to the best of my knowledge. I understand that any materially false statement, omission, or misrepresentation may be grounds for denial of credentialing or immediate termination of affiliation.

I authorize any person, institution, medical group, health plan, professional licensing board, law enforcement agency, or insurance carrier to release to the requesting organization or its agents any information required to verify the information provided herein, including primary source verification of education, training, licensure, board certification, work history, hospital privileging and professional liability history. I waive any claims against such persons or entities for furnishing requested information in good faith.

This authorization is valid until: . I understand I may revoke this authorization in writing; however, such revocation will not affect information already released in reliance on this authorization.

I understand that credentialing decisions are based on primary source verification and evaluation of professional qualifications and that submission of this application does not guarantee approval or privileging.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with or offered the Notice of Privacy Practices describing how protected health information may be used or disclosed in connection with credentialing and peer review activities. I consent to release of my professional information as necessary for credentialing, quality assessment, and payer enrollment.

Acknowledged: (check to acknowledge)

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