Can a PD Listing be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and most states’ UETA frameworks so long as intent, consent, attribution, and retention requirements are met.

Do PHI elements require special handling?

Yes. Any PHI included in a PD Listing or its attachments must be handled under HIPAA; use a vendor that supports a Business Associate Agreement (BAA) and appropriate encryption and access controls.

When is notarization required?

Notarization is only required when a specific attestation or legal form calls for it. State rules vary; when required, consider Remote Online Notarization if permitted by state law.

What if provider data changes after publication?

Document the update with an amended listing version, record the effective date, retain the prior version per retention policy, and notify payers if contractual obligations require.

How long must I keep signed listings?

Retention depends on record category: follow HIPAA (6 years) for PHI and IRS or contractual rules for financial records; consult the organization retention schedule for specifics.

Who should sign provider attestations?

An authorized representative—typically the provider, medical director, or credentialing officer—must sign. Verify signer authority in payer contracts or internal delegation policies.

Electronic Signature
Templates
Healthcare
Healthcare PD Listing

Healthcare PD Listing

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare PD Listing

Patient Information

Full legal name Date of birth Gender Address

Primary phone

Email

Emergency contact (name and phone)

Insurance Information

Insurance provider

Policy number

Group number

Subscriber name

Medical Summary

Current medications (name, dose, frequency) Allergies / adverse reactions Prior surgeries / significant medical history Chronic conditions

Primary care provider

Preferred pharmacy

Purpose of Listing

Check all purposes for which the patient data may be included on the PD Listing:

Care coordination among treating providers

Referral and transfer of care

Insurance verification and billing

Quality improvement and population health

Other:

Authorized Recipients and Information to Be Disclosed

The following recipients are authorized to receive the listed patient data for the purposes selected above.

Other treating providers and specialists

Hospitals and emergency departments

Health plan / payer for benefits coordination

Family member / caregiver: Relationship:

Research entity (requires separate consent)

Select categories of information to be disclosed:

Demographics (name, address, phone)

Clinical summaries and problem list

Medication lists and prescriptions

Laboratory and imaging results

Mental health records (explicit consent acknowledges sensitive nature)

Substance use treatment records (explicit consent acknowledges federal privacy protections)

HIV-related information (requires explicit authorization)

Genetic test results (sensitive information)

Duration, Revocation, and Expiration

This authorization is valid until: . If no date is provided, this authorization will expire one year from the date of signature.

I understand that I may revoke this authorization at any time by delivering a written revocation to the releasing organization. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

Privacy Acknowledgment

I acknowledge that I have read and understand that my protected health information described above may be disclosed to the authorized recipients. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. I understand that signing this authorization is voluntary and that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization unless allowed by law.

By checking the box below I expressly authorize the release of the categories of information I have selected.

I acknowledge and authorize the disclosures described above

Certification and Signature

I certify that the information provided on this Healthcare PD Listing is true and accurate to the best of my knowledge. I authorize the release of the specified information for the purposes indicated. I understand that sensitive information (including mental health, substance use, HIV-related, and genetic information) will be released only if I have specifically authorized that category. I understand my rights to revoke this authorization and the effects of revocation as described above.

Printed name of signer:

Signature:

Date:

If signer is not the patient, indicate relationship to patient:

What the Healthcare PD Listing Is and What It Records

A Healthcare PD Listing is a structured provider directory record used by health systems, payers, and credentialing teams to publish and maintain provider data including legal name, NPI, specialty taxonomy, practice locations, contact details, credential expirations, and participation status. Accurate PD listings support patient access, claims routing, network directories, and payer enrollment. When completed electronically the listing can be routed, signed, and retained under ESIGN (15 U.S.C. ch. 96) and state electronic transaction laws such as UETA. For protected health information (PHI) elements, workflows must also meet HIPAA requirements and any applicable state privacy rules.

Why a Complete, Compliant PD Listing Matters

A precise Healthcare PD Listing reduces claim denials, supports accurate network directories, and decreases administrative rework. It also creates an auditable record for payer contracts and credentialing while aligning with ESIGN for electronic acceptance and HIPAA rules for PHI handling.

Who Typically Prepares and Maintains a PD Listing

Several roles touch PD listings during onboarding and lifecycle maintenance; responsibilities vary by organization and by workflow authority.

Health system administrators responsible for network data and public-facing directories, ensuring accuracy across hospital sites and clinics.
Credentialing and privileging teams that verify licensure, DEA, board certifications, and expiration dates for compliance and insurer requirements.
Payer provider relations and contracting staff who confirm network participation, taxonomies, and billing addresses for claims processing.

Assign clear ownership for initial entry, periodic verification, and updates to reduce discrepancies and maintain regulatory compliance.

Essential Components of a Professional Healthcare PD Listing

A complete listing groups identity, licensure, practice details, coverage participation, availability, and verification evidence. Each component helps downstream systems—scheduling, billing, and public directories—rely on a single authoritative record.

Provider Identity

Full legal name, professional suffixes, and known aliases tied to the National Provider Identifier (NPI) to avoid mismatches in claims or credentialing.

Licenses & Credentials

State medical license numbers, issuing state, expiration dates, board certifications, and DEA numbers where applicable to support privileging and regulatory checks.

Practice Locations

Complete addresses, phone numbers, taxonomies, and service locations; include effective dates for location changes and note primary practice site.

Network Participation

Payer IDs, contracted networks, effective/term dates, and billing addresses to ensure correct claims routing and patient eligibility verification.

Availability & Hours

Clinic hours, on-call arrangements, telehealth availability, and scheduling notes so directories reflect real-time patient access options.

Verification Evidence

Attachments such as scanned licenses, certificates, board letters, and signed attestation statements archived alongside the listing for audit readiness.

Stepwise Process to Complete and Approve a PD Listing

Follow these sequential steps to reduce errors and create an auditable record that satisfies credentialing and payer needs.

01

Collect source documents: Gather licenses, DEA, certificates, and NPI verification.
02

Populate listing: Enter fields according to the fillable fields guide.
03

Review and validate: Credential team confirms accuracy and attachments.
04

Sign and archive: Obtain signed attestation and store audit trail.

Where to Send, File, or Publish the Completed Listing

Determine destination based on intended audience: internal directories, payer enrollment portals, public listings, or credentialing repositories.

Internal EHR: Import listing to the EHR provider directory module.
Payer Portals: Submit payer-facing data to contracted payers or clearinghouses.
Public Directory: Publish verified contact and access details for patient search tools.
Credential Archive: Store signed evidence in secure credentialing records.

Technical and Platform Considerations for eCompletion

Electronic completion and eSignature require platform support for common file formats, secure storage, and integration with clinical and payer systems.

File formats: PDF, Word DOCX, and structured exports (CSV/Excel) supported.
Integrations: Connectors for EHRs and CRMs like Epic, Allscripts, Salesforce, and NetSuite.
Authentication: Email, SMS, or advanced signer authentication available.

Platform Notes on Security and Interoperability

Choose a solution that supports HIPAA controls, audit trails, accessible export formats, and integrations to minimize manual rekeying and preserve the signing certificate.

Storage: AES-256 at rest; TLS 1.2/1.3 in transit.
Audit: Detailed timestamp, IP, and action logs expected.
Export: PDF/A or signed PDF export with certificate.

Security and Compliance Checklist for Electronic PD Listings

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

HIPAA: Supports HIPAA compliance; BAA required

Audit Trail: Timestamped logs with IP attribution

Standards: SOC 2 Type II and ISO 27001 certified

21 CFR: 21 CFR Part 11 capabilities available

Accessibility: WCAG 2.0 Level AA compliant

Key Risks and Potential Consequences of Errors

Credentialing Delay: Missed appointments or onboarding postponements

Claim Denials: Incorrect payer IDs cause reimbursement issues

HIPAA Violation: Unauthorized PHI disclosure leads to enforcement

Contract Penalties: Payer contracts may impose sanctions

Patient Access Impact: Outdated hours or locations harm access

Reputational Harm: Public directory errors undermine trust

Common Mistakes When Preparing a Healthcare PD Listing

Entering informal or abbreviated provider names instead of exact legal names, which causes mismatches in licensing and billing systems and triggers rework.
Failing to attach source documents like state licenses or DEA certificates, leaving credentialing reviewers unable to verify status and delaying approvals.
Neglecting to update effective or termination dates for network participation, resulting in incorrect patient eligibility or claims routing errors.
Using a P.O. box for primary practice addresses where payers require a physical service location, leading to payment or enrollment complications.

Comparing eSignature Vendor Pricing and Key Features

Pricing and core capabilities vary by vendor; signNow is listed first with its verified starting price and plan characteristics for straightforward comparison.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About Healthcare PD Listings and eSigning

Answers to common questions on legality, signatures, retention, and practical steps to resolve errors when completing or submitting a PD listing.

Need help? Contact support

Can a PD Listing be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and most states’ UETA frameworks so long as intent, consent, attribution, and retention requirements are met.
Do PHI elements require special handling?
Yes. Any PHI included in a PD Listing or its attachments must be handled under HIPAA; use a vendor that supports a Business Associate Agreement (BAA) and appropriate encryption and access controls.
When is notarization required?
Notarization is only required when a specific attestation or legal form calls for it. State rules vary; when required, consider Remote Online Notarization if permitted by state law.
What if provider data changes after publication?
Document the update with an amended listing version, record the effective date, retain the prior version per retention policy, and notify payers if contractual obligations require.
How long must I keep signed listings?
Retention depends on record category: follow HIPAA (6 years) for PHI and IRS or contractual rules for financial records; consult the organization retention schedule for specifics.
Who should sign provider attestations?
An authorized representative—typically the provider, medical director, or credentialing officer—must sign. Verify signer authority in payer contracts or internal delegation policies.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now