California Participating Practitioner Form PDF Details

In the landscape of healthcare provision in California, the California Participating Practitioner Application, specifically Addendum B, plays a vital role in ensuring the transparency and accountability of practitioners within the medical field. This form is a requisite document that needs to be completed by medical practitioners looking to affiliate with healthcare organizations, detailing their involvement in professional liability lawsuits or arbitration actions over the past seven years. It requires comprehensive completion to facilitate the expedited processing of the practitioner's application, asking for detailed information regarding any pending, settled, or concluded lawsuits or arbitrations, irrespective of the outcome or the presence of any financial settlement on behalf of the practitioner. This includes the practitioner's identification details, case specifics such as patient information, the incident leading to the lawsuit or arbitration, and the current status of the case, including any financial settlements made. Significantly, it mandates the disclosure of insurance coverage or other financial protections available to the practitioner, highlighting the system's emphasis on comprehensive risk management. Additionally, it provides a mechanism for healthcare organizations to conduct thorough credentialing and peer review processes, aimed at maintaining high standards of patient care and professional conduct within their institutions. By mandating the submission of such detailed information and ensuring its confidentiality, the form serves as a critical tool in safeguarding patient welfare and upholding the integrity of the medical profession in California.

QuestionAnswer
Form NameCalifornia Participating Practitioner Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names2012, participating application addendum, cppa addendum a form california, credentialing

Form Preview Example

California Participating Practitioner Application

Addendum B

Professional Liability Action Explained

This Addendum is submitted to

herein, this Healthcare Organization

Please complete this form for each pending, settled or otherwise conclude professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past seven (7) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Addendum B prior to completing, and complete a separate form for each lawsuit.

Please check here if there are no pending/settled claims to report (and sign below to attest).

I. Practioner Identifying Information

Last Name:

First Name:

Middle:

II. Case Information

Patient's Name:

City, County, State where lawsuit filed:

 

Patient Gender

Male

Female

Patient DOB:

 

 

 

 

 

 

 

 

 

Court Case number, if known:

Date of alleged incident serving as Date suit filed:

 

 

 

basis for the

 

 

 

 

 

 

 

lawsuit/

 

 

 

 

 

 

 

arbitration:

 

 

 

 

 

 

 

 

 

 

 

Location of incident:

 

Hospital

My Office

Other doctor's office

Surgery Center

Other (specify)

Relationship to patient (Attending physician, Surgeon, Assistant, Consultant, etc.)

Allegation

Is/was there an insurance company or other liability protection company or

 

 

organization providing coverage/defense of the lawsuit or arbitration action?

Yes

No

 

 

If yes, please provide company name, contact person, phone number, location and carrier's claim identification number, or other liability protection company or organization.

If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney as this will serve as your authorization:

Name:

Telephone Number:

Fax Number:

California Participating Physician Application - ADDENDUM A

1

Version 1.2012

III. Status of Lawsuit/Arbitration (check one)

Lawsuit/arbitration still ongoing, unresolved.

Judgment rendered and payment was made on my behalf.

Judgment rendered and I was found not liable.

Lawsuit/arbitration settled and payment made on my behalf.

Amount paid on my behalf:

Amount paid on my behalf:

Lawsuit/arbitration settled/dismissed, no judgment rendered, no payment made on my behalf.

Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheets.

Please include:

1.Condition and diagnosis at the time of incident,

2.Dates and description of treatment rendered, and

3.Condition of patient subsequent to treatment.

SUMMARY

I certify that the information in this document and any attached documents is true and correct. I agree that “this Healthcare Organization”, its representatives, and any individuals or entities providing information to this Healthcare Organization in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document, which is part of the California Participating Practitioner Application. In order for the participating healthcare organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Healthcare Organization about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorney(s) listed on Page 1 to discuss any information regarding this case with “this Healthcare Organization”.

APPLICANT SIGNATURE (Stamp is Not Acceptable)

PRINTED NAME

DATE

California Participating Practitioner Application - ADDENDUM B

2

Version 1.2012

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Step 1: First, access the editor by clicking the "Get Form Button" above on this page.

Step 2: As you start the PDF editor, you will get the form prepared to be filled in. Other than filling in various fields, you might also do several other things with the PDF, including putting on custom text, modifying the original textual content, inserting illustrations or photos, putting your signature on the PDF, and a lot more.

If you want to fill out this form, make certain you provide the necessary information in every single blank:

1. The california participating physician application 2019 usually requires particular details to be typed in. Be sure the subsequent blank fields are completed:

2012 completion process explained (part 1)

2. Just after this part is filled out, go on to type in the suitable details in these - City County State where lawsuit, Court Case number if known, Date of alleged incident serving, Date suit filed, Location of incident, Hospital, My Office, Other doctors office, Surgery Center, Other specify, Relationship to patient Attending, Allegation, Iswas there an insurance company, Yes, and If yes please provide company name.

Allegation, If yes please provide company name, and Yes in 2012

People generally get some things incorrect while filling in Allegation in this section. Be certain to go over everything you enter right here.

3. This third stage is going to be straightforward - complete all of the fields in If you would like us to contact, Telephone Number, Fax Number, California Participating Physician, and Version to conclude this part.

Step no. 3 of filling in 2012

4. To go forward, this form section requires typing in several blank fields. Examples include Lawsuitarbitration still ongoing, Judgment rendered and payment was, Amount paid on my behalf, Judgment rendered and I was found, Lawsuitarbitration settled and, Amount paid on my behalf, Lawsuitarbitration, Summarize the circumstances giving, Please include Condition and, and SUMMARY, which are key to moving forward with this process.

Amount paid on my behalf, Lawsuitarbitration, and SUMMARY in 2012

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