Practitioner Credentialing Form Practice Name: * Person Completing This Form: * First Name Last Name Contact Phone: * (###) ### #### Contact Email: * Practitioner Name: * First Name Last Name Practitioner Email: * Type 1 NPI: * Type 2 NPI (if applicable): Taxonomy code: * NPPES Username: * NPPES Password: * D.O.B: * MM DD YYYY Gender * Social Security #: * Other Names Used: Do you have a complete CAQH Profile: * Yes No CAQH ID: * CAQH User Name: CAQH Password: * Primary Office Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Office Phone: * (###) ### #### Primary Office Fax: (###) ### #### Primary Office Email: * Primary Office Hours and Days Opened: * Identify how your business is registered with the IRS (sole proprietor, LLC, Non-Profit...): * Mailing Office Address: (if different from office address) Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Office Phone: (if different from office address) (###) ### #### Mailing Office Fax: (if different from office address) (###) ### #### Mailing Office Email: (if different from office address) Do you render services at other facilities or practice locations * Yes No If Yes Please list Address and Phone number if different: All Education & Training is shown on CV: * WE MUST HAVE MM/YYYY FOR EACH EDUCATION & TRAINING ENTRY Yes No Do you want to list any Professional Associations? * Yes No Professional Associations List any foreign languages Spoken: Primary Specialty: * Board Certified (Primary Specialty): Yes No 2nd Specialty (if applicable): Do you have any hospital affiliations? Yes No Hospital Affiliation 1: (If not on CV) Provide detailed items that are not contained on your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Issue State: (If not on CV) Issued Date: (If not on CV) MM DD YYYY Expiration Date: (If not on CV) MM DD YYYY Restrictions: Status Active Inactive Hospital Affiliation 2: (If not on CV) Issue State: (If not on CV) Issued Date: (If not on CV) MM DD YYYY Expiration Date: (If not on CV) MM DD YYYY Restrictions: Status: Active Inactive License Type: * License Number: * Issue State: * Issuing Board: * Issued Date: * MM DD YYYY Expiration Date: * MM DD YYYY Restrictions: * Status * Active Inactive Special Certifications: * License Number: * Start Date: * MM DD YYYY End Date: * MM DD YYYY Medicare ID (PTAN): * Medicaid ID: Current Policy Number Carrier: * Coverage Start Date: * MM DD YYYY Coverage End Date: * MM DD YYYY Claims Made Yes No Single Limits: * Aggregate Limits: * Do you have other coverage to report? *If yes, please send a seperate email and attach a copy of proof of insurance Yes No Undergraduate School Name: * Date graduated: * MM DD YYYY Degree earned: * Graduate School Name: * Date graduated: * MM DD YYYY Degree earned: * Any Gaps in work history * Yes No If yes – Explain: Reference 1: * Please Provide: Name Address Phone Number Specialty Email Reference 2: * Please Provide: Name Address Phone Number Specialty Email Reference 3: * Please Provide: Name Address Phone Number Specialty Email 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 Have you ever received a reprimand or been fined by any state licensing board? * Yes No Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than noncompletion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board? * Yes No Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? * Yes No 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 (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? * Yes No 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? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? * Yes No Have any of your board certifications or eligibility ever been revoked? * Yes No Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes No Have you had any malpractice actions within the past 10 years (pending, settled, arbitrated, mediated, or litigated)? * If yes, provide information for each case via email Yes No Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? * Yes No Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional? * Yes No Thank you!
