Idaho Practitioner Application Form – Fill Out and Use This PDF

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Initial Practitioner Credentialing Application Checklist

Thank฀you฀for฀your฀interest฀in฀Blue฀Cross฀of฀Idaho.฀Use฀this฀checklist฀to฀ensure฀proper฀ completion฀of฀the฀enclosed฀Idaho฀Practitioner฀Application฀–฀September฀2014.฀

•฀฀ Completed฀Application:฀Ensure฀all฀sections฀of฀the฀application฀are฀complete฀or฀indicate฀ “Does฀Not฀Apply”฀as฀appropriate.฀Please฀be฀aware฀that฀referencing฀“Curriculum฀Vitae”฀ or฀“CV”฀are฀not฀acceptable฀substitutes฀for฀completing฀the฀application.

•฀ ฀Licenses:฀List฀all฀current฀and฀expired฀state฀professional฀licenses,฀including฀those฀for฀Idaho.฀

(PAGE 2, SECTION V)

•฀฀฀ DEA฀Registration:฀Provide฀DEA฀registration฀information,฀as฀applicable.฀

(PAGE 2, SECTION IV)

•฀฀฀ Education:฀Provide฀education฀information,฀complete฀with฀start฀and฀end฀dates.฀

(PAGES 2-4 SECTION VI, VII, VIII)

•฀฀฀ Certiications:฀Provide฀board฀and฀any฀other฀applicable฀certiication฀information.฀(PAGE 4, SECTION XIV).฀In฀addition,฀nurse฀practitioners฀and฀allied฀health฀practitioners฀must฀provide฀ copies฀of฀professional฀certiications.฀(I.E. AANP, ANCC, CCNA, CRNA ETC.)

•฀฀฀ Hospital฀Afiliations:฀List฀current,฀primary฀admitting฀facility฀along฀with฀other฀current฀or฀ pending฀hospital฀afiliations. (PAGE 5, SECTION XVI)

•฀฀฀ Work฀History:฀Provide฀complete฀work฀history฀and฀explain฀lapses฀for฀the฀previous฀ive฀years฀ or฀since฀earning฀degree.฀(PAGE 6, SECTION XVII)

•฀฀฀ Liability฀Insurance:฀Include฀copy฀of฀current฀professional฀liability฀insurance฀face฀sheet฀ showing฀minimum฀requirements฀of฀$1,000,000/$3,000,000฀in฀coverage.

•฀฀฀ Idaho฀Practitioner฀Attestation฀Questions฀Form:฀Provide฀a฀completed,฀signed,฀dated฀and฀

unaltered฀copy.฀Provide฀written฀explanation฀for฀any฀“Yes”฀answers.฀(pages฀9฀and฀10)

•฀฀฀ Release฀of฀Authorization฀Form:฀Provide฀a฀completed,฀signed,฀dated฀and฀unaltered฀copy.฀

(PAGE 11)

Please฀note:฀Your฀application฀information฀cannot฀be฀more฀than฀180฀days฀old฀at฀the฀time฀of฀ Blue฀Cross฀of฀Idaho฀review.฀On฀average,฀our฀credentialing฀process฀takes฀60฀to฀90฀days.฀Please฀ make฀sure฀you฀provide฀ample฀processing฀time฀when฀signing฀and฀submitting฀your฀application.฀ We฀cannot฀accept฀or฀process฀incomplete฀or฀outdated฀applications.฀Lack฀of฀correct฀information฀ will฀delay฀your฀ability฀to฀contract฀with฀Blue฀Cross฀of฀Idaho.

We฀accept฀applications฀via฀fax฀at฀208-387-6818฀or฀emailed฀to฀PR2PI@BCIDAHO.COM.

For฀credentialing฀questions,฀please฀call฀208-286-3447฀or฀208-472-5112.

(REVISED: 9/2014)

3000฀E.฀Pine฀Avenue,฀Meridian,฀ID฀83642-5995฀•฀P.O.฀Box฀7408,฀Boise,฀ID฀83707-1408฀•฀(208)฀345-4550฀•฀www.bcidaho.com

An Independent Licensee of the Blue Cross and Blue Shield Association

Applicant Rights for Credentialing and Recredentialing

•฀ Applicants฀have฀the฀right,฀upon฀request,฀to฀be฀informed฀of฀the฀status฀of฀their฀application.฀ Applicants฀may฀contact฀credentialing฀staff฀via฀telephone฀or฀in฀writing฀to฀inquire฀as฀to฀the฀ status฀of฀their฀application.

•฀ Credentialing฀staff฀will฀respond฀to฀the฀applicant’s฀request฀for฀information฀either฀via฀ telephone฀or฀in฀writing฀of฀the฀status฀of฀their฀application฀within฀ifteen฀(15)฀calendar฀days.฀ Blue฀Cross฀of฀Idaho฀is฀not฀required฀to฀provide฀the฀applicant฀with฀information฀that฀is฀peer- review฀protected.฀Information฀reported฀to฀the฀National฀Practitioner฀Data฀Bank฀(NPDB)฀is฀ considered฀conidential฀and฀shall฀not฀be฀disclosed.฀An฀applicant฀will฀be฀advised฀that฀they฀ may฀complete฀a฀self-query฀to฀obtain฀information฀that฀is฀contained฀in฀the฀NPDB.

•฀ Applicants฀have฀the฀right฀to฀review฀the฀information฀submitted฀in฀support฀of฀their฀ credentialing฀application.฀This฀review฀is฀at฀the฀applicant’s฀request.

•฀ The฀applicant฀will฀be฀notiied฀in฀writing฀of฀initial฀credentialing฀decisions฀within฀sixty฀ (60)฀days฀of฀being฀reviewed฀for฀credentialing.

•฀ Credentialing฀staff฀will฀notify฀the฀applicant฀in฀writing฀of฀any฀information฀obtained฀during฀

the฀credentialing฀process฀that฀varies฀signiicantly฀from฀the฀information฀provided฀to฀

Blue฀Cross฀by฀the฀applicant.

•฀ Should฀the฀information฀provided฀by฀the฀applicant฀on฀their฀application฀vary฀substantially฀ from฀the฀information฀obtained฀and/or฀provided฀to฀Blue฀Cross฀of฀Idaho฀by฀other฀individuals฀ or฀organizations฀contact฀as฀part฀of฀the฀credentialing฀and/or฀recredentialing฀process,฀ credentialing฀staff฀will฀contact฀the฀applicant฀via฀fax,฀mail฀or฀email฀to฀advise฀the฀applicant฀of฀ the฀variance฀and฀provide฀the฀applicant฀with฀the฀opportunity฀to฀correct฀the฀information฀if฀it฀ is฀erroneous.

•฀ The฀applicant฀will฀submit฀any฀corrections฀in฀writing฀within฀thirty฀(30)฀calendar฀days฀to฀ the฀credentialing฀staff.฀Any฀additional฀documentation฀will฀be฀kept฀as฀part฀of฀the฀applicant’s฀ credential฀ile.

3000฀E.฀Pine฀Avenue,฀Meridian,฀ID฀83642-5995฀•฀P.O.฀Box฀7408,฀Boise,฀ID฀83707-1408฀•฀(208)฀345-4550฀•฀www.bcidaho.com

An Independent Licensee of the Blue Cross and Blue Shield Association

Idaho Practitioner Application

To use the Idaho Practitioner Application (IPA), follow these instructions

Complete the application in its entirety using black or blue ink. Keep an unsigned and undated copy of the application on file for future requests. When a request is received, send a copy of the completed application, making sure that all information is complete, current and accurate. Please sign and date pages 9 , 10, and 11. Please document any YES responses on the Attestation Question page.

Prior to submitting this application to any health care related organization, inquire with the organization, as you may need authorization (through a pre-application process) before the application is accepted. Identify the health care related organization(s) to which this application is being submitted in the space provided below.

Attach copies of requested documents each time the application is submitted.

If changes must be made to the completed application, strike out the information and write in the modification, initial and date.

If a section does not apply to you, please check the provided box at the top of the section.

Expect addendums from the requesting organizations for information not included on the IPA.

This application is submitted to

I. INSTRUCTIONS

II. PRACTITIONER INFORMATION

This form should be typed or legibly printed in black or blue ink. If more space is needed than provided, attach additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the following documents must be submitted

with this application (all are required for MDs, DOs; as applicable for other health practitioners). If not available, indicate why.
∙	State Professional License(s)	∙ Passport photo (for hospitals only)
∙ DEA Certificate w/ Idaho address		∙	Face Sheet of Professional Liability Policy or Certificate
∙	ECFMG (if applicable)	∙	Curriculum Vitae (Not an acceptable substitute for completing

∙ ISBP Certificate

the application.)

** All sections must be completed in their entirety.**

Last name (include suffix; Jr., Sr., III)

First (do not abbreviate)

Middle (do not abbreviate)

Other name(s) under which you have been known by reference, licensing and or educational institutions?

Degree(s)

Home telephone number

Pager number

Cell number

E-mail address

Home mailing address

City

State

Zip code

Birth Date

Birth place (city, state, country)

Social security number

Citizenship

Languages spoken by practitioner

Specialty

Gender

PCP

Urgent Care

Specialist

Male

Female

NPI

Medicare UPIN

Medicare number (ID)

Medicaid number(s)

Other professional interests in practice, research, etc.

Specialty

Subspecialties

III. PRACTICE INFORMATION

Effective Date at Primary Practice location __________

Name of practice, affiliation or clinic name				Department name (if hospital based)

Primary office street address		City		State	Zip code

Patient appointment telephone number	Fax number		Name affiliated with tax ID number		Federal tax ID number

Mailing address (if different from above)		City		State	Zip code

Idaho Practitioner Application –September 2014

Page 1 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

III. PRACTICE INFORMATION (CONTINUED)

Billing address (if different from above)		City	State	Zip code

Office manager / Administrator name	Administration telephone number		Fax number	E-mail address

Credentialing contact (if different from above)	Credentialing telephone number		Fax number	E-mail address

Effective Date at Secondary Practice location

Name of secondary practice, affiliation or clinic name					Department name (if hospital based)

Secondary office street address			City		State	Zip code

Patient appointment telephone number	Fax number			Name affiliated with tax ID		Federal tax ID number
				number

Mailing address (if different from above)			City		State	Zip code

Billing address (if different from above)			City		State	Zip code

Office manager / Administrator name		Administration telephone number			Fax number	E-mail address

Credentialing contact (if different from above)		Credentialing telephone number			Fax number	E-mail address

List other office locations with above information on a separate sheet.

PROFESSIONAL	LICENSURE
IV.

Idaho State professional license/registration/certificate number

Issue date	Expiration date

Drug Enforcement Administration (DEA) registration number

State controlled substance certificate number

ECFMG number (applicable to foreign medical graduates)

Status

Active Inactive Temporary

Name of sponsor if required by licensure, (i.e. Physician’s Assistant).

Issue date		Expiration date
Issue date		Expiration date

	Date issued

POROFESSIONALTHER	LICENSES	State
POROFESSIONALTHER	LICENSES	Expiration date
		Expiration date
		State
		Expiration date
ALL		State
ALL
V.		Expiration date
V.
-UGRADUATENDER	EDUCATION	Name of college or university


		Degree received
		Degree received
		Mailing address
		Mailing address
		Name of college or university
		Degree received
VI.		Mailing address

Idaho Practitioner Application –September 2014

License/registration/certificate number			Date Issued

	Year relinquished	Reason

License/registration/certificate number			Date Issued

	Year relinquished	Reason

License/registration/certificate number			Date Issued

	Year relinquished	Reason

					Does Not Apply
			Graduation date
			Graduation date

		City		State		Zip code
			Graduation date



		City		State		Zip code

Page 2 of 11	Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

(Do not abbreviate) (Attach additional sheet if necessary)

MEDICAL/PROFESSIONAL	EDUCATION
VII.

Medical/Professional school

Start date

Mailing address

Medical/Professional School

Start date

Mailing address

Graduation date		Degree received

	City		State		Zip code

	Phone			Fax
Graduation date		Degree received



	City		State		Zip code

	Phone			Fax

(Do not abbreviate) (Attach additional sheet if necessary)

Institution

Does Not Apply

GVIII.RADUATE EDUCATION

Program or course of study

Faculty director

Mailing address

City

State

Zip code

Dates attended

Phone

Fax

(

) - (

)

(Do not abbreviate) (Attach additional sheet if necessary)

Institution

Does Not Apply

/PGYINTERNSHIP

Program director

Mailing address

City

State

Zip code

Start date

Completion date

Phone

Fax

IX. I

Type of internship

Specialty

Did you successfully complete the program?

Yes

(If "No", please explain on separate sheet.)

(Do not abbreviate) (Attach additional sheet if necessary)

Institution

Does Not Apply

Program director

Mailing address

City

State

Zip code

Start date

Completion date

Phone

Fax

ESIDENCIES

Type of residency

Specialty

Did you successfully complete the program?

Yes

Does Not Apply

(If "No", please explain on separate sheet.)

Institution

Program director

Mailing address

City

State

Zip code

Start date

Completion date

Phone

Fax

Type of residency

Specialty

Did you successfully complete the program?

Yes

(If "No", please explain on separate sheet.)

Idaho Practitioner Application –September 2014

Page 3 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

Idaho Practitioner Application –September 2014

(Do not abbreviate) (Attach additional sheet if necessary)

Institution

Program director

Mailing address

Start date

Course of study

XI. FELLOWSHIPS

	Did you successfully complete the program?		Yes	No	(If "No", please explain on separate sheet.)

Institution								Does Not Apply
								Does Not Apply

Program director

Mailing address						City	State		Zip code

Start date		Completion date				Phone		Fax

Course of study

	Did you successfully complete the program?		Yes	No	(If "No", please explain on separate sheet.)

XII. PRECEPTORSHIP

(Do not abbreviate) (Attach additional sheet if necessary)

Institution

				Does Not Apply

Department chairman

Mailing address		City	State		Zip code

Start date	Completion date	Phone		Fax

Training

XIII. FACULTY

APPOINTMENT

Institution

Faculty director

Mailing address

Start date

Position

(Do not abbreviate) (Attach additional sheet if necessary)

XIV. BOARD CERTIFICATION

(Do not abbreviate) (Attach additional sheet if necessary)

Are you board or otherwise professionally certified?				Does Not Apply

Yes If "Yes", please complete below		No If "No", describe your intent for certification, if any, and dates of
		testing for Certification on separate sheet.
Issuing Board/Entity	State		Date	Date	Expiration Date
Issuing Board/Entity	Issued	Specialty	Certified	Recertified	(if any)
	Issued	Specialty	Certified	Recertified	(if any)

Have you applied for certification other than those indicated above?

Yes

If so, list certification and date

If you participate in a specialty which does not have board certification, please indicate specialty

Page 4 of 11 Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

(Do not abbreviate) (Attach additional sheet if necessary)

			ACLS, BLS, ATLS, PALS, NRP, NALS			Does Not Apply
			(i.e., Fluoroscopy, Radiography, etc. – Attach certificate if applicable)			Does Not Apply

OXV.THER ERTIFICATIONSC		Type		Number		Expiration date

		Type		Number		Expiration date
		Type		Number		Expiration date

		Type		Number		Expiration date

		Type		Number		Expiration date


		XVI.			Does Not Apply

			Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) have current
HOSPITAL AND
HOSPITAL AND			affiliations, (B) applications in process, (C) have had previous affiliations or, if no current affiliation, (D) have a current
	OTHER
	OTHER		coverage plan. This includes hospitals, surgery centers, institutions, corporations, military assignments, or government
INSTITUTIONAL
INSTITUTIONAL			agencies. If more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII,
AFFILIATIONS
AFFILIATIONS			Work History.
			Work History.
			(Do not abbreviate) (Attach additional sheet if necessary)

A. CURRENT AFFILIATIONS

Name of primary facility

(Do you have admitting privileges?

Yes

No)

Department

Department / Clinical Chair

Status (active, provisional, courtesy, temporary, etc.)

Mailing address

City

State

Zip code

Phone number

Fax number

Appointment date

Name of secondary facility

(Do you have admitting privileges?

Yes

No)

Department

Department / Clinical Chair

Status (active, provisional, courtesy, temporary, etc.)

Mailing address

City

State

Zip code

Phone number

Fax number

Appointment date

Name of other facility (Do you have admitting privileges?

Yes

No)

Department

Department / Clinical Chair

Status (active, provisional, courtesy, temporary, etc.)

Mailing address

City

State

Zip code

Phone number

Fax number

Appointment date

B. APPLICATIONS IN PROCESS

(Do not abbreviate) (Attach additional sheet if necessary)

Hospital/Institution

Mailing address		City	State	Zip code

Phone number	Fax number		Date application submitted

Hospital/Institution

Mailing address		City	State	Zip code

Phone number	Fax number		Date application submitted

Idaho Practitioner Application –September 2014

Page 5 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

(Do not abbreviate) (Attach additional sheet if necessary)

	Name of facility							Does Not Apply
								Does Not Apply

	Department			Department / Clinical Chair

	Mailing address		City			State			Zip code

	Phone number	Fax number		Previous status (active, provisional, courtesy, temporary, etc.)

	Reason for leaving						Appointment date (from– to)
FFILIATIONS
FFILIATIONS	Name of facility
	Name of facility

	Department			Department / Clinical Chair

A	Mailing address		City			State			Zip code
A
PREVIOUS
PREVIOUS	Phone number	Fax number		Previous status (active, provisional, courtesy, temporary, etc.)
	Phone number	Fax number

	Reason for leaving						Appointment date (from– to)
C.
C.	Name of other facility
	Name of other facility

	Department				Department / Clinical Chair

	Mailing address		City			State			Zip code

	Phone number	Fax number		Previous status (active, provisional, courtesy, temporary, etc.)

	Reason for leaving						Appointment date (from– to)

NPATIENTCOVERAGE -	ON-CALL PLAN
D. I

For those without admitting privileges, please attach signed letter of agreement from the physician

or group representative that admits and manages the inpatient care for your patients.

Does Not Apply

For those with admitting privileges, please list the physicians who provide call coverage for you.

Name of admitting physician/practice/clinic/group	Hospital where privileged

(Do not abbreviate) (Attach additional sheet if necessary)

Chronologically list all work history activities since completion of professional training (use extra sheets if necessary). This information

must be complete. A curriculum vitae is not sufficient.

Name of current practice/employer

ISTORY

Contact name

Telephone number

Fax number

From

Mailing address

City

State

Zip code

WORK

Name of practice/employer

XVII.

Contact name

Telephone number

Fax number

From

Mailing address

City

State

Zip code

Reason for leaving

Idaho Practitioner Application –September 2014

Page 6 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

	Name of practice/employer
(CONTINUED)
(CONTINUED)	Contact name		Telephone number	Fax number		From		To
	Contact name		Telephone number	Fax number		From		To

	Mailing address				City		State	Zip code

ISTORY	Reason for leaving

	Please account for all gaps in time between date of medical / professional school graduation to present not covered elsewhere
H		within this application. Include dates, activity and names where applicable.
WORK
WORK		Activity / Name				From		To
		Activity / Name				From		To
XVII.
XVII.

(Do not abbreviate)

XVIII. PROFESSIONAL AFFILIATIONS

Please List Membership In All Professional Societies	Date Joined	Current Member
Complete Name of Society	Date Joined	Current Member
Complete Name of Society
		Yes	No

REFERENCES

List three professional references, from your specialty area, not including relatives, who have worked with you in the past two years. References must be from individuals who through recent observation, are directly familiar with your work and can attest to your clinical competence in your specialty area. One reference must be from same discipline.

Name of reference			Title and specialty

Mailing address		City		State		Zip code

E-mail address	Telephone number	Fax number			Cell phone number (optional)

Name of reference			Title and specialty

XIX. PEER

Mailing address		City		State		Zip code

E-mail address	Telephone number	Fax number			Cell phone number (optional)

Name of reference			Title and specialty

Mailing address		City		State		Zip code

E-mail address	Telephone number	Fax number			Cell phone number (optional)

Idaho Practitioner Application –September 2014

Page 7 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

Idaho Practitioner Application –September 2014

(Do not abbreviate)

Current insurance carrier

Policy number

Mailing address

City

State

Zip code

Phone number

Fax number

Origination (retroactive) date

Per claim amount

Aggregate amount

Effective date

Expiration date

LIABILITY

Please list ALL professional liability carriers within the past ten years

Mailing address

City

State

Zip code

Name of carrier

Policy number

PROFESSIONAL

Phone number

Fax number

From

Name of carrier

Policy number

XX.

Mailing address

City

State

Zip code

Phone number

Fax number

From

Name of carrier

Policy number

Mailing Address

City

State

Zip code

Phone number

Fax number

From

XXI. PROFESSIONAL LIABILITY ACTION DETAIL – CONFIDENTIAL

Practitioner name(print or type)

Does Not Apply

Please list any past or current professional liability claim(s) or lawsuit(s), in which allegations of professional negligence were made against you, whether or not you were individually named in the claim or lawsuit. Please do not include patient names or other HIPAA protected health information (PHI). Photocopy this page as needed and submit a separate page for EACH claim/event. A legible signed practitioner narrative that addresses all of the following details is an acceptable alternative.

Date and clinical details of the incident, with preceding events

Date

Details

Your role and specific responsibility in the incident

Subsequent events, including patient’s clinical outcome

Date suit or claim was filed

Name and Address of Insurance Carrier that handled the claim

Your status in the legal action (primary defendant, co-defendant, other)

Current status of suit or other action

Date of settlement, judgment, or dismissal

If case was settled out-of-court, or with a judgment, settlement amount attributed to you? $

Page 8 of 11 Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

IDAHO PRACTITIONER ATTESTATION QUESTIONS - To be completed by the practitioner

Please circle your answer to EACH of the following questions. If you circle 'Yes", provide details as specified on a separate sheet. If you attach additional sheets, sign and date each sheet.

A.	PROFESSIONAL SANCTIONS
	Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited,
	sanctioned, placed on probation, monitored, or not renewed for any of the following? Or have you voluntarily or involuntarily
	relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to
	preclude an investigation or while under investigation relating to professional competence or conduct?
	a.	License to practice any profession in any jurisdiction	Yes	No

	b.	Other professional registration or certification in any jurisdiction	Yes	No

	c.	Specialty or subspecialty board certification	Yes	No

	d.	Membership on any hospital medical staff	Yes	No

	e.	Clinical privileges at any facility, including hospitals, ambulatory surgical centers, skilled nursing facilities, etc.	Yes	No

	f.	Medicare, Medicaid, FDA, governmental, national or international regulatory agency or any public program	Yes	No

	g.	Professional society membership or fellowship	Yes	No

	h.	Participation/membership in an HMO, PPO, IPA, PHO or other entity	Yes	No

	i.	Academic Appointment	Yes	No

	j.	Authority to prescribe controlled substances (DEA or other authority)	Yes	No

	Have you ever been subject to review, challenges, and/or disciplinary action, formal or informal, by an ethics committee,		Yes	No
	licensing board, medical disciplinary board, professional association or education/training institution?
	Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in		Yes	No
	applicable state provisions?
	Have you ever been the subject of any reports to a state, federal, national data bank, or state licensing or disciplinary		Yes	No
	entity?
B.	CRIMINAL HISTORY

	Have you ever been charged with a criminal violation (felony or misdemeanor) resulting in either a plea bargain,
	conviction on the original or lesser charge, or payment of a fine, suspended sentence, community service or other		Yes	No
	obligation?
	a.	Do you have notice of any such anticipated charges?	Yes	No

	b.	Are you currently under governmental investigation?	Yes	No

C.	AFFIRMATION OF ABILITIES

	Do you presently use any drugs illegally?		Yes	No

	Do you have, or have you ever had, any physical condition, mental health condition, or chemical dependency condition
	(alcohol or other substance) that affects or could affect your current ability to practice with or without reasonable
	accommodation? If reasonable accommodation is required, specify the accommodations required. If the answer to this		Yes	No
	question is yes, please identify and describe any rehabilitation program in which you are or were enrolled which assures
	your ability to adhere to prevailing standards of professional performance.
	Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner
	agreement/hospital agreement, with or without reasonable accommodation, according to accepted standards of		Yes	No
	professional performance?

LITIGATION AND MALPRACTICE COVERAGE HISTORY (If you answer "Yes" to any of the questions

D.in this section, please document in Section XXI. PROFESSIONAL LIABILITY ACTION DETAIL of this application.)

	Have allegations or claims of professional negligence been made against you at any time, whether or not you were	Yes	No
	individually named in the claim or lawsuit?
	Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a professional malpractice	Yes	No
	claim (not necessarily a lawsuit) and/or to satisfy a judgment (court-ordered damage award) in a professional lawsuit?
	Are there any such claims being asserted against you now?	Yes	No

	Have you ever been denied professional liability coverage or has your coverage ever been terminated, not renewed,	Yes	No
	restricted, or modified (e.g. reduced limits, restricted coverage, surcharged)?
	Are any of the privileges that you are requesting not covered by your current malpractice coverage?	Yes	No

E.Attestation

I warrant that all the statements made on this form and on any attached information sheets are complete, accurate, and current. I understand that any material misstatements in, or omissions from, this statement constitute cause for denial of membership or cause for summary dismissal from the entity to which this statement has been submitted.

	Typed or printed name		Signature	Date
Idaho Practitioner Application –September 2014		Page 9 of 11	Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

XXII. ATTESTATION

I certify the information in this entire application is complete, accurate, and current. I acknowledge that any misstatements in or omissions from this application constitute cause for denial of membership or cause for summary dismissal from the entity to which this statement has been made. A photocopy of this application has the same force and effect as the original. I have reviewed this information as of the most recent date listed below.

Print Name Here

Signature

(Stamped signature is not acceptable)

Date

Review dates and initials

Idaho Practitioner Application –September 2014

Page 10 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

Authorization for Release of Information

By submitting this Authorization for Release of Information form in conjunction with the Idaho Practitioner Application or Blue Cross of Idaho recredentialing application, I understand and agree as follows:

1.I understand and acknowledge that, as an applicant for participating status with Blue Cross of Idaho for initial credentialing or recredentialing, I have the burden of producing adequate information for proper evaluation of my competence, character, ethics, mental and physical health status, and or other qualifications in a timely manner. I understand that the application will not be processed until Blue Cross of Idaho deems the application complete.

2.I further understand and acknowledge that Blue Cross of Idaho or designated agent will investigate the information in this application. By submitting this application, I agree to such investigation and to the disciplinary reporting and information exchange activities of Blue Cross of Idaho as part of the verification and credentialing process.

3.I authorize all individuals, institutions and entities or organizations with which I am currently or have been associated and all professional liability insurers with which I have had or currently have professional liability insurance, who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information to Blue Cross of Idaho, their staffs and agents.

4.I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry out the clinical privileges or provide services I request. I authorize each and every individual and organization in custody of such records and documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested.

5.I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction with providing information, investigating and evaluating my application and qualifications, and I waive all legal claims against any representative of Blue Cross of Idaho or its respective agent(s) who act in good faith and without malice in connection with the investigation of this application.

6.I understand and agree that the authorizations and releases given by me herein shall be valid so long as I am an applicant for or have participating status at Blue Cross of Idaho, unless revoked by me in writing.

7.I acknowledge that I have been informed of, and hereby agree to abide by Blue Cross of Idaho rules, regulations, contractual agreements, and policies.

8.I acknowledge that I am responsible for notifying Blue Cross of Idaho of any changes/challenges to licensure, DEA, malpractice claims, criminal convictions, hospital privileges or other disciplinary actions.

9.I attest to the accuracy, currency and completeness of the information provided. I understand and agree that any misstatements in or omissions from the application and attachments hereto may constitute cause for denial of the application or summary dismissal or termination of participation agreement.

10.I agree to exhaust all available procedures and remedies as outlined in the, rules, regulations, and policies, and/or contractual agreement of Blue Cross of Idaho before initiating judicial actions.

11.I understand that completion and submission of the Authorization for Release does not automatically grant me participating status with Blue Cross of Idaho.

12.I further acknowledge that I have read and understand the foregoing Authorization for Release of Information. A photocopy of this Authorization for Release of Information shall be as effective as the original and authorization constitutes my written authorization and request to communicate any relevant information and to release any and all supportive documentation regarding this application/attestation.

Print Name:___________________________________________________

Signature:_____________________________________________________ Date:___________________

Stamped signature is not acceptable

Modification to the wording or formation of the Authorization for Release of Information may invalidate an application.

Idaho Practitioner Application –September 2014

Page 11 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

Question	Answer
Form Name	Idaho Practitioner Application Form
Form Length	13 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 15 sec
Other names	idaho credentialing online, id credentialing, blue cross practitioner, id practitioner

Does Not Apply

Completion date