HR CAQH Document

HR CAQH Document

Personal Information

Date of Birth:   Last 4 of SSN:

Primary Phone:   Secondary Phone:

Position Information

Reporting Manager:   Anticipated Start Date:

Employment Type: Full-Time Part-Time Contractor Per Diem

CAQH / Professional Identifiers and Licensure

NPI Number:   Primary Taxonomy:

License Expiration Date:   DEA / Other Controlled Substances #:

Employment History — Most Recent Employer

Start Date:   End Date:

Employment History — Prior Employer

Start Date:   End Date:

Education

Graduation Date:   Major / Field:

References

Phone:   Email:

Phone:   Email:

Phone:   Email:

Professional Disclosures

Please answer the following. Check "Yes" only if applicable. If Yes, provide a full explanation and attach documentation as required.

1. Have you ever had disciplinary action, restriction, suspension, or limitation placed on any professional license or clinical privileges?    Yes    No

2. Have you been named in any malpractice claims or suits within the last ten years?    Yes    No

3. Have you ever been convicted of a felony or misdemeanor that has not been annulled, expunged, or sealed?    Yes    No

Legal Disclosures and Authorizations

At-Will Employment: I understand that, if hired, my employment is at will and may be terminated by me or the employer at any time, with or without cause or prior notice, subject only to applicable law. Nothing in this document creates a contract of employment for any definite term.

Equal Opportunity: The organization is an equal opportunity employer and does not discriminate based on race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic in accordance with applicable law.

Authorization to Release and Verify Information: I authorize the release to the organization and to CAQH, its agents and authorized representatives, of any and all information, records or documents necessary to verify the information contained in this form, including but not limited to professional licenses, education, employment history, malpractice history, criminal background, and sanctions screening. I further authorize prior employers, educational institutions, licensing boards, malpractice carriers and others to provide such information. I waive any claim I may have against any party for providing such information in good faith.

Consent for Background Checks and Federal/State Screening: I consent to the organization conducting criminal background checks, exclusion list screening, National Practitioner Data Bank queries, OIG/GSA sanctions checks, and verification of credentials as required for credentialing and privileging purposes. I understand that adverse findings may affect eligibility for employment or privileging.

Attestation to Accuracy: I attest under penalty of perjury that all information provided on this form is true, correct and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of material facts may result in denial of application, withdrawal of a job offer, termination of employment, and potential civil or criminal liability.

Applicant Authorization Confirmation: I have read and agree to the authorizations and attestations above.

Applicant Certification

I certify that all information provided in this HR CAQH Document is accurate, complete, and provided voluntarily for the purposes of credentialing, privileging, employment, and participation in applicable payer networks. I understand that additional documentation may be requested to substantiate the statements herein. I authorize verification and release of any information necessary to complete credentialing and employment processes.

Sign Now