Healthcare Recredentialing Application

HEALTHCARE RECREDENTIALING APPLICATION

This application is for recredentialing of a healthcare practitioner for participation with the organization's provider network. Completion of this form authorizes the organization and its agents to verify credentials, licensure, and other information necessary to evaluate ongoing participation. Complete all sections fully; omissions may delay processing.

APPLICANT INFORMATION

MD    DO    NP    PA    Other:

Date of Birth:    Gender:

LICENSURE AND BOARD CERTIFICATION

Provide all active state professional licenses. If more than three, attach a complete list to this application.

Issue Date:    Expiration Date:

Issue Date:    Expiration Date:

EDUCATION, TRAINING, AND CERTIFICATION

Graduation Year:

Certification Number:    Initial Certification Date:    Expiration:

HOSPITAL PRIVILEGES & PRACTICE LOCATIONS

Privileges Status:    Effective Date:    Expiration Date:

MALPRACTICE INSURANCE

Policy Limits:    Expiration Date:

EMPLOYMENT / PROFESSIONAL HISTORY (PAST 5 YEARS)

List positions for the past five years. If additional space is required, attach a separate signed sheet.

MALPRACTICE CLAIMS / ADVERSE ACTIONS

Have any malpractice claims, suits, settlements, judgments, disciplinary actions, investigations, or terminations occurred against you since your last credentialing?   Yes    No

Have you ever been the subject of any professional review action, limitation, or restriction by any hospital, health plan, professional society, licensing board, or government agency?   Yes    No

PROFESSIONAL REFERENCES

AUTHORIZATION, ATTESTATION AND RELEASE

I certify that the information provided in this recredentialing application is true, complete, and accurate to the best of my knowledge. I understand that omission of information, misstatement, or falsification may be grounds for denial, termination, or other corrective action.

I authorize the organization, its agents, and any designated third parties to obtain and verify information from any source relevant to my credentials, including primary source verification of education, training, licensure, board certification, malpractice history, and professional references. I release from liability all individuals and institutions providing such information.

I understand that this authorization remains in effect until the authorization expiration date provided below, after which a new signed authorization will be required for further verification.

I acknowledge receipt of the organization’s privacy and data use practices as they relate to credentialing data and consent to the use and disclosure of my credentialing information for purposes of quality assurance, peer review, payment, and regulatory compliance consistent with applicable law.

Consent to primary source verification: I consent.

HIPAA acknowledgment: I acknowledge that I have been informed of the organization’s privacy practices as related to provider credentialing data.

ATTESTATION (SIGNATURE)

By signing below, I attest under penalty of perjury and other applicable penalties that the information provided in this application and any attachments is true, correct, and complete. I understand this attestation is subject to verification.

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