Minnesota Uniform Credentialing Application Form – Fill Out and Use This PDF

The Minnesota Uniform Credentialing Application form serves as a comprehensive document designed for the reappointment of physicians, dentists, and allied health professionals in Minnesota. This meticulously structured form requests detailed information ranging from personal data, credentialing contact information, to practice history, ensuring that all relevant data for credentialing is provided accurately and completely. Professionals are guided through a series of sections to furnish details about their personal background, professional training, employment history, and affiliations, making it a critical step for maintaining their credentials.

If you are looking to renew your professional medical credentials in Minnesota, ensure your reappointment process is seamless by accurately completing the Minnesota Uniform Credentialing Application. Click the button below to begin filling out your form.

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Minnesota Uniform Credentialing Application Form PDF Details

The Minnesota Uniform Credentialing Application form serves a critical function for physicians, dentists, and allied health professionals in Minnesota seeking reappointment or credentialing. This comprehensive document requires applicants to provide detailed personal data, including any former aliases and language fluency, which is vital for healthcare facilities to ensure quality and comprehensive care. It mandates explicit information about practice locations, both primary and additional, illustrating the need for a transparent account of an applicant's professional environment and affiliations. Furthermore, the form delves into the professional training backgrounds since the last reappointment, including fellowships and academic affiliations, ensuring that practitioners are up to date in their respective fields. Employment and practice history form another essential component, demanding a chronological account to identify any potential gaps in practice which might need clarification. Hospital affiliations are thoroughly examined, requiring details on admitting privileges, which is central to understanding a practitioner's network and capacity for patient care. Instructions stipulate that all information must be black ink or electronically generated, highlighting the importance of clarity and legibility in these submissions. By requiring signatures and dates on key sections like disclosure questions, attestation, and authorization releases, the form emphasizes accountability, consent, and transparency between healthcare providers and credentialing bodies.

Question	Answer
Form Name	Minnesota Uniform Credentialing Application Form
Form Length	18 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 30 sec
Other names	minnesota credentialing form, minnesota uniform credentialing application, application credentialing, minnesota uniform credentialing application initial

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Minnesota Uniform Credentialing Application

Reappointment

Physician/Dentist/Allied Health Professional

Applicant Name (as shown on your state license):

___________________________________________________________________________________________________________

	Last	First	Middle	Suffix	Title

CREDENTIALING CONTACT INFORMATION
Name	_________________________________________________________		Phone Number _______________________________
Address	_________________________________________________________		Fax Number	_______________________________
	_________________________________________________________		E-mail ______________________________________
	_________________________________________________________

This Box to be Completed by Allied Health Professionals Only

Profession/Title _______________________________________________________

Sponsoring/Collaborative Physician _______________________________________

(Must complete if PA-C or APRN)

Instructions

The reappointment application and attachments should be filled out completely and accurately and must be legible or electronically generated. If more space is needed than provided on the application, please attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. ALL SIGNATURES AND DATES MUST BE CLEARLY LEGIBLE.

Please verify that you have:

Provided complete street address, phone, fax and e-mail addresses wherever indicated, including education/training, past employment, hospital affiliations & references



Designate dates by month, day and year time frames

Answered all of the Disclosure Questions on Pages 10 and 11 and enclosed explanations for affirmative answers

Signed and dated the Attestation Signature and Date statement (Page 12)

Signed and dated the Authorization and Release (Page 13)

All Information Must Be Printed in Black Ink or Electronically Generated

Reappointment Application – 09/2001; Revised 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, Revised 10/2016

Page 1 of 17

Personal Data

Name (as shown on your state license):

__________________________________________________________________________________________________________________

LastFirstMiddleSuffixTitle

All Former Aliases: _____________________________________ Spouse Name (optional): ________________________________________

Date of Birth: ___________________________________ Gender:  Male  Female

Social Security Number: ___________________________________ NPl: _______________________________________________________

Current Home Address: ______________________________________________________________________________________________

Street

__________________________________________________________________________________________________________________


	City/State/Country		Zip Code
Preferred Mailing Address:  Office	 Home	Practitioner’s Preferred E-mail address: ___________________________________

Cell Phone Number: ___________________________________ Home Phone Number: ___________________________________________

Do you speak a language other than English with sufficient fluency to treat patients who speak only that language?  Yes  No

If yes, specify languages: _____________________________________________________________________________________________

Primary or Pending Practice Location

Primary Practice Location/Clinic Name: __________________________________________________________________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Office Phone Number: ______________________________________ Fax Number: ______________________________________________

Federal Tax ID Number: ______________________________________ Type II NPI: _____________________________________________

E-mail Address: _____________________________________________________________________________________________________

Start Date (at this location): ___________________________________________________________

Practicing as:  Primary Care	 Specialist	 Urgent Care	 Locum Tenens		 Moonlighting Resident	 Hospitalist
 Hospital Based only	Teaching/Research only		 Other (specify) ________________________________________
Accepting new patients?  Yes	 No	Directory Suppress?	 Yes	 No

Primary Specialty in which care will be provided: ___________________________________________________________________________

Sub Specialty (ies) in which care will be provided: __________________________________________________________________________

Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet):

__________________________________________________________________________________________________________________

Reappointment Application – 09/2001; Revised 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, Revised 10/2016

Page 2 of 17

Additional Practice Location(s) – Since Last Reappointment Applicant Name:

Other Practice Name: ____________________________________________________ Phone Number: ___________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

E-mail Address: __________________________________________ Fax Number: _______________________________________________

Federal Tax ID Number (if different from primary): _____________________________ Type II NPI: __________________________________

Credentialing Contact: ________________________________________________________ Phone Number: __________________________

Start Date (at this location): ___________________________________________________________

Practicing as:  Primary Care	 Specialist	 Urgent Care	 Locum Tenens		 Moonlighting Resident	 Hospitalist
 Hospital Based only	Teaching/Research only		 Other (specify) ________________________________________
Accepting new patients?  Yes	 No	Directory Suppress?	 Yes	 No

Primary Specialty in which care will be provided: ___________________________________________________________________________

Sub Specialty (ies) in which care will be provided: __________________________________________________________________________

Fellowship/Post-Graduate/Professional Training – Since your last reappointment

(Month, day and year required)
From: _______________		Institution Name: _____________________________________________________________________________
To:	_______________	Type of Program/Specialty: _____________________________________________________________________
		Completed Training:  Yes  No If no, expected completion date: ___________________________________
		If not successfully completed, explain: ____________________________________________________________
		Program Director: ____________________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: ___________________________________ Fax Number: _______________________________
		E-mail address: ______________________________________________________________________________
Professional and Academic/Faculty Affiliations - Since your last reappointment

(Month, day and year required)
From: _______________		Institution Name: _____________________________________________________________________________
To:	_______________	Appointment Held/Position: _____________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code

Phone Number: _____________________________________ Fax Number: _____________________________

E-mail address: ______________________________________________________________________________

Reappointment Application – 09/2001; Revised 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, Revised 10/2016

Page 3 of 17

Chronological Employment/Practice History (include Military Service)	Applicant Name:

(Additional space is provided on the Chronological Employment/Practice History Addendum. You may make extra copies of page 15 for additional employments.)

Chronological listing [month/day/year] of employment/practice history since your last reappointment. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOCLOGY.

(Month, day and year required)

From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: ________________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?

 Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

	Street	City/State/Country	Zip Code
	Phone Number: ______________________________________ Fax Number: ____________________________
	E-mail address: ______________________________________________________________________________
From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: ________________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?

 Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

	Street	City/State/Country	Zip Code
	Phone Number: ______________________________________ Fax Number: ____________________________
	E-mail address: ______________________________________________________________________________
From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: ________________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?

 Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ______________________________________ Fax Number: ____________________________

E-mail address: ______________________________________________________________________________

Check here if you have additional employment history on attached Chronological Employment/Practice History Addendum (page 15)

Time Gaps: Explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice - since your last reappointment (if additional space is required, you may make extra copies of page 15 for additional time gaps.)

(Month, day and year required)

From: _______________		Explain: ____________________________________________________________________________________
To:	_______________	___________________________________________________________________________________________
From: _______________		Explain: ____________________________________________________________________________________
To:	_______________	___________________________________________________________________________________________

Check here if you have additional time gap information on attached Chronological Employment/Practice History Addendum (page 15)

Reappointment Application – 09/2001; Revised 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, Revised 10/2016

Page 4 of 17

Primary Hospital Affiliation	Applicant Name:

(pertinent to Primary or Pending Practice Location listed on page 2)

If no hospital admitting privileges, describe method/coverage for continuity of care. Please provide covering physician’s name, if applicable.

_________________________________________________________________________________________________________________

(Month, day and year required)
From: _______________	Facility Name: _______________________________________________________________________________
To: _______________	Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
 Application Pending	Department Chairperson: ______________________________________________________________________
	Address: ___________________________________________________________________________________
	Street	City/State/Country	Zip Code
	Phone Number: _____________________________________ Fax Number: _____________________________
	E-mail address: _____________________________________________________________________________
Admitting Privileges:	 Yes  No (If no, please complete box above)

Other Hospital Affiliations - Since your last reappointment (Additional space is provided on the Hospital Affiliation Addendum. You may make extra copies of page 16 for additional affiliations.)

(Month, day and year required)
From: _______________		Facility Name: _________________________________________________________________________
To:	_______________	Former Facility Name (if applicable): ____________________________________________		Facility Still Open?
				 Yes  No

		Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
 Application Pending		Department Chairperson: ______________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: _____________________________________ Fax Number: _____________________________
		E-mail address: ______________________________________________________________________________
Admitting Privileges:		 Yes  No (If no, please complete box above)
From: _______________		Facility Name: _________________________________________________________________________
To:	_______________	Former Facility Name (if applicable): ____________________________________________		Facility Still Open?
				 Yes  No

		Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
 Application Pending		Department Chairperson: ______________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: _____________________________________ Fax Number: _____________________________
		E-mail address: ______________________________________________________________________________
Admitting Privileges:		 Yes  No (If no, please complete box above)

Check here if you have additional hospital affiliations on attached Hospital Affiliation Addendum (page 16)

Reappointment Application – 09/2001; Revised 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, Revised 10/2016

Page 5 of 17

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Minnesota Uniform Credentialing Application Form – Fill Out and Use This PDF

Minnesota Uniform Credentialing Application Form PDF Details

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