Healthcare Physician Application

HEALTHCARE PHYSICIAN APPLICATION

Purpose: This application is a formal request for appointment, reappointment, or enrollment as a medical staff member or participating physician with the organization. Completion of this application authorizes the organization and its agents to verify and investigate all statements contained herein, to obtain primary source verification of credentials, and to obtain criminal background checks, malpractice history, and other relevant information necessary for privileging or enrollment decisions.

1. APPLICANT IDENTIFICATION

Full legal name:

NPI (National Provider Identifier):    State medical license number:

License State:    License Issue Date:    License Expiration Date:

Male   Female   Non-binary   Prefer not to disclose

2. CONTACT INFORMATION

3. PROFESSIONAL IDENTIFIERS & CREDENTIALS

DEA Expiration Date:    Medicare PTAN (if applicable):

Policy number:    Limits of liability:

4. EDUCATION, TRAINING, AND CERTIFICATION

Degree and graduation year:

Date certified:    Certification expiration:

5. PROFESSIONAL EXPERIENCE

6. MALPRACTICE, DISCIPLINARY, AND LEGAL HISTORY

Have you ever had a medical malpractice claim filed against you, or been involved in a settlement, judgment, or pending claim?   Yes No

Have you ever been subject to disciplinary action, investigation, limitation, or restriction by any licensing board, hospital, payer, or professional organization?   Yes No

Have you ever been convicted of a felony or misdemeanor related to practice or professional conduct?   Yes No

Are you currently excluded, suspended, or debarred from participation in federal or state healthcare programs (e.g., Medicare, Medicaid)?   Yes No

7. REFERENCES

8. ATTACHMENTS CHECKLIST

Please indicate documents attached with this application:

Current curriculum vitae
Copy of state medical license(s)
Board certification documentation
DEA certificate
Malpractice insurance declaration page

9. AUTHORIZATION, ATTESTATION, AND RELEASE

By signing below, I hereby certify that the information contained in this application and any attachments is true, complete, and correct to the best of my knowledge. I understand that omission of material facts, misstatements, or falsification of information is grounds for denial of appointment, discipline, or termination of participation.

I authorize the organization, its agents, and representatives to consult with and obtain information from my references, current and prior employers, licensing and disciplinary authorities, malpractice carriers, and other entities necessary to evaluate my application. I release from liability any person or entity which provides information in good faith to the organization and waive any claims against the organization that may arise from the verification of credentials or investigation of my background.

I consent to primary source verification of my education, training, licensure, board certification, and other credentials, and to the release of information to payors, credentialing organizations, and regulatory bodies where required. This authorization shall remain valid for the duration necessary to complete the review process and for purposes of reappointment or enrollment unless revoked in writing.

Sign Now