Texas Standardized Credentialing Application Form

Texas Standardized Credentialing Application

(Please type or print)

Section I

Personal Information

Other Name Used (Maiden/Other):    Years Associated with Former Name (yyyy - yyyy):    Other Name Used:    Years Associated with Former Name (yyyy - yyyy):    Gender: Male Female

Home Mailing Address: City: State: ZIP Code: Home Telephone Number:

Date of Birth (mm/dd/yyyy): Place of Birth: Citizenship: If not American Citizen, Status and Visa Number: Are you eligible to work in the United States? Yes No

Are you currently on active military duty or on military reserve? Yes No

US Military Service/Public Health N/A Yes    Dates of Service From (mm-dd-yyyy) – To (mm-dd-yyyy): Last Location: Branch of Service:

Practice Location Information

Type of Service Provided: Primary Care Specialty Care    Type of Professional (Physician, Nurse, Physical Therapist, Counselor):

Primary Office Address - Street: City: State: ZIP Code:

Primary Office Telephone Number: Primary Office Fax Number: Primary Office Email Address: Tax ID Number and Associated Individual Group Number and Name (for this location):

Are you currently practicing at the location above? Yes No    If No, what is your expected start date?

Other Office Address - Street: City: State: ZIP Code:

Do you want this site listed in the Directory? Yes No    Telephone Number: Fax Number: Email Address: Tax ID Number and Associated Individual Group Number and Name (for this location):

Other Office Address - Street: City: State: ZIP Code:

Do you want this site listed in the Directory? Yes No    Telephone Number: Fax Number: Email Address: Tax ID Number and Associated Individual Group Number and Name (for this location):

Correspondence Office Address - Street: City: State: ZIP Code:

Telephone Number: Fax Number: Email Address:

If you have additional offices, please submit an attachment containing the above information and check this box

License and Other Identification Numbers

License Information – Include all license(s) and certifications in all States where you are currently or have previously been licensed

Disclosure Questions

Section II

PLEASE ANSWER EACH QUESTION AND INCLUDE AN EXPLANATION FOR ANY QUESTION ANSWERED YES.

1. Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board? Yes No

2. Have you ever received a reprimand or been fined by any state licensing board? Yes No

3. Have your clinical privileges at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions? Yes No

4. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? Yes No

5. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations? Yes No

6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? Yes No

7. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes No

8. Have any of your board certifications or eligibility ever been revoked? Yes No

9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? Yes No

Malpractice Actions

19. Have you ever had any malpractice actions? Yes No

If yes, provide information below:

Signature

Authorization, Acknowledgement, Attestation and Release

Section III

(Not for Use for Employment Purposes)

I understand and agree that, as part of the credentialing application process for participation and/or clinical privileges, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation.

I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information I have provided.

I further acknowledge that I have read and understand the foregoing Authorization, Acknowledgement, Attestation and Release and agree that a facsimile or photocopy shall be as effective as the original.