Healthcare Provider Credentialing

HEALTHCARE PROVIDER CREDENTIALING APPLICATION

Provider Identifying Information

Provider Name:

Personal Details

Date of Birth:   Gender:   NPI Number:

Licensure and Certification

Primary State Medical License Number:   State:   Issue Date:   Expiration Date:

Board Certified: Yes No

Education and Training

Hospital Privileges and Affiliations

Professional Liability Insurance

Malpractice Carrier:   Policy Number:

Limits of Liability:   Policy Effective Date:   Policy Expiration Date:

Professional History and Disclosures

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

Have you been subject to any malpractice claim, settlement, or judgment within the last ten years? Yes No

Credentialing References

Medicare / Medicaid / Payer Enrollment

Are you currently enrolled in Medicare? Yes No

Are you currently enrolled in any state Medicaid program? Yes No

Release, Authorization, and Attestation

By signing below, I certify that all information supplied in this application is true, correct and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of material facts may be grounds for denial, rescission, or termination of credentialing and participation with the organization and may be reported to state licensing and other regulatory bodies where required.

I expressly authorize the organization, its agents and contractors to verify all information contained herein, to obtain professional references, to contact educational institutions, licensing boards, malpractice carriers and employers, and to request and receive any records or other information relevant to my credentialing and privileging. I release from liability all individuals and entities who provide such information in good faith.

I authorize the release of my credentialing application, credentialing file, and any adverse action information to payers, hospitals, facilities, and other organizations for purposes of credentialing and quality assurance. This authorization shall remain in effect until the authorization expiration date below unless revoked in writing. I understand that revocation will not affect disclosures made prior to receipt of such written revocation.

I expressly consent to criminal background checks, verification of Medicare/Medicaid sanctions and exclusions, OIG/GSA/HHS checks, and any other checks reasonably required by the organization as part of the credentialing process.

Acknowledgment and Certification

I certify under penalty of perjury that the information provided on this application is true and accurate. I understand that submission of this application does not guarantee approval, and that final credentialing decisions are subject to the policies and procedures of the organization.

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