Minnesota Uniform Credentialing Application (Reappointment) at a glance
What it is: This is the Minnesota Uniform Credentialing Application, the reappointment application for a physician, dentist or allied health professional.
Who signs: You sign and date the Attestation Signature and Date statement. You sign and date the Authorization and Release.
What to bring and attach to Minnesota Uniform Credentialing Application (Reappointment)
Liability Insurance: enclose a copy of professional liability insurance coverage (e.g., face sheet/verification of self-insurance) for primary practice location to include effective dates, insurance carrier, expiration date, coverage limits, and name of each provider covered.
List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills.
Do not include your residency director, fellowship director, relatives, or pending partners.
At least one reference should be in your specialty (and if possible from the same subspecialty).
A filled-in Minnesota Uniform Credentialing Application (Reappointment) example: a physician assistant fills page one
How to fill out Minnesota Uniform Credentialing Application (Reappointment), box by box
Credentialing contact information
Enter the Applicant Name as shown on your state license: Last, First, Middle, Suffix and Title.
Under CREDENTIALING CONTACT INFORMATION, fill in the Name, Phone Number, Address, Fax Number and E-mail.
This Box to be Completed by Allied Health Professionals Only
This box is to be completed by Allied Health Professionals only.
Enter the Profession/Title.
Enter the Sponsoring/Collaborative Physician; you must complete it if you are a PA-C or APRN.
More rules for Minnesota Uniform Credentialing Application (Reappointment)
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, attach additional sheets and reference the question being answered. Do not use abbreviations when completing the application. All signatures and dates must be clearly legible.
I understand and agree that any material misstatement in or omission from the Application may constitute grounds for denial or revocation of Participation.
Race and ethnicity information is for health plan use only and is optional.
Check the box if you do not wish for your race and/or ethnicity to be displayed in provider directories.
Providing race and/or ethnicity information on the credentialing application is entirely optional, and refusal to provide this information will NOT subject you to adverse treatment.
This information will not be considered in making any decisions regarding your credentialing.
If this describes you
You are filling in Personal Data
Personal Data: write your name as shown on your state license.
List All Former Aliases; the Spouse Name is optional.
Enter your Date of Birth and mark your Gender, Male or Female.
Mark your Preferred Mailing Address, Office or Home.
Mark Yes or No: do you speak a language other than English with sufficient fluency to treat patients who speak only that language. If yes, specify languages.
Under Practicing as, mark Primary Care, Specialist, Urgent Care, Locum Tenens, Moonlighting Resident or Hospitalist.
Provide a narrative description of your clinical practice including special interests; if additional space is required, attach a separate sheet.
You are listing training, affiliations or employment
Under Fellowship/Post-Graduate/Professional Training - Since your last reappointment, month, day and year are required.
Under Professional and Academic/Faculty Affiliations - Since your last reappointment, month, day and year are required.
Chronological listing [month/day/year] of employment/practice history since your last reappointment.
Clinic Still Open? Yes or No. If no, attach sheet listing address and phone number of someone who can verify your time there.
Under Time Gaps, explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice since your last reappointment.
If no hospital admitting privileges, describe method/coverage for continuity of care.
You are listing Licensure, DEA Registration or life support certifications
Under Licensure, list all past, current and pending professional licenses.
Drug Enforcement Administration Registration: the address on the DEA certificate must be in state where you will be practicing as applicable to this application.
If you do not maintain a DEA certificate, please explain.
State Controlled Substance Certification/Registration: if applicable; not applicable to MN, WI, ND.
Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)? Yes or No.
Continuing Education Attestation: please read the attestation carefully before signing and dating the statement.
You are answering the Disclosure Questions
Disclosure Questions for Reappointment Credentialing: please provide a complete explanation if any of the following questions is answered in the affirmative. Use a separate sheet to continue, if necessary.
12. Mark Yes or No: in the past three years, have you ever had any professional liability claims or lawsuits brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or final judgments? If yes, please complete the enclosed Malpractice Litigation and Professional Complaints Addendum.
A previously completed application is being reviewed and updated
Update Attestation Signature and Date: the signature blocks are to be signed ONLY if a previously completed application is being reviewed and updated.
Sign only one of the attestation blocks, reconfirming that the application is complete, true and accurate.
Before you go
Provide a complete street address, phone, fax and e-mail address wherever indicated, including education/training, past employment, hospital affiliations and references.
Designate dates by month, day and year time frames.
Answer all of the Disclosure Questions and enclose explanations for affirmative answers.
You sign and date the Attestation Signature and Date statement.
You sign and date the Authorization and Release.
All information must be printed in black ink or electronically generated.
Common questions about Minnesota Uniform Credentialing Application (Reappointment)
Who signs it?
You sign and date the Attestation Signature and Date statement. All signatures and dates must be clearly legible or signed with a unique electronic identifier.
What am I certifying when I sign?
Attestation Signature and Date: by signing, you certify that all the information on this application form is complete, true and accurate. You further agree to update this information as necessary so that it remains complete, true and accurate while your application is being processed.
Sources
[1] Minnesota Uniform Credentialing Application, Reappointment Physician/Dentist/Allied Health Professional (the served file; no issuer file found) (the Official source link on this page).