Minnesota Uniform Credentialing Application Form PDF Details

For anyone who works in the medical field, hearing about a new credentialing application can be an overwhelming experience. Whether you are a doctor, nurse practitioner, hospital administrator or any other health care provider looking to start practicing in Minnesota—the process of applying for credentials is not only complex, but time-consuming. To simplify the process and streamline the timeline for getting approved, Minnesota has developed a Uniform Credentialing Application Form which serves as one standardized form for all applicants wishing to practice within the state. This helpful guide will provide information regarding this application form and detailed steps on what is needed to fill it out correctly and submit it successfully.

QuestionAnswer
Form NameMinnesota Uniform Credentialing Application Form
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namesminnesota credentialing form, minnesota uniform credentialing application, application credentialing, minnesota uniform credentialing application initial

Form Preview Example

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

Specialty/Subspecialty Certification

Applicant Name:

 

 

(Additional space is provided on the Specialty and Licensure Addendum, page 17. You may make extra copies of page 17 or attach a separate sheet for additional Specialty and Licensure.)

Primary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Secondary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Check here if you have additional specialty on attached Specialty and Licensure Addendum (page 17)

If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Licensure - List all past, current and pending professional licenses.

(Additional space is provided on the Specialty and Licensure Addendum, page 17. You may make extra copies of page 17 or attach a separate sheet for additional Specialty and Licensure.)

License Type

State

License Number

Date Issued

Expiration Date

License Status

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 17)

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

Page 6 of 17

Drug Enforcement Administration Registration

Applicant Name:

NOTE: Address on DEA certificate must be in state where you will be practicing as applicable to this application.

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

If you do not maintain a DEA certificate, please explain:

Not applicable to practice DEA certificate pending; date application submitted to DEA: ___________________________________

Other _____________________________________________________________________________________

State Controlled Substance Certification/Registration (If applicable - not applicable to MN, WI, ND).

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Life Support Certification

Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)?

Yes No

If Yes: Type of Certification

Expiration Date(s)

___________________________________________________________

_______________

___________________________________________________________

_______________

___________________________________________________________

_______________

___________________________________________________________

_______________

Continuing Education Attestation

Please read the following attestation carefully before signing and dating the statement.

I hereby certify that I have a sufficient number of CE credits to meet the licensure requirements and attest that an appropriate percentage relate to my specialty. I understand that these credits may be audited by an individual facility based on their individual requirements.

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Signature: __________________________________________________________ Date: _________________________

Name: ______________________________________________________________________________________________

(please print or type)

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

Page 7 of 17

Liability Insurance

Applicant Name:

Insurance Carrier for Primary and Pending Practice Location (You may attach a separate sheet for additional 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. If additional space is required, attach a separate sheet.

Coverage dates:

(Month, day and year required)

Start:

_______________

Current Insurance Carrier Name: ___________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ________________________________ Fax Number: _____________________________

 

 

E-mail address: _________________________________________________________________________

Certificate Pending

Name in which policy issued: ______________________________________________________________

 

 

Policy number: __________________________________________________________________________

 

 

Amount of coverage (per occurrence): _______________________________________________________

 

 

Amount of coverage (per aggregate): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ________________________________ Fax Number: _____________________________

 

 

E-mail address: _________________________________________________________________________

 

 

Name in which policy issued: ______________________________________________________________

 

 

Policy number: __________________________________________________________________________

 

 

Amount of coverage (per occurrence): _______________________________________________________

 

 

Amount of coverage (per aggregate): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

Phone Number: ________________________________ Fax Number: _____________________________

E-mail address: _________________________________________________________________________

Name in which policy issued: ______________________________________________________________

Policy number: __________________________________________________________________________

Amount of coverage (per occurrence): _______________________________________________________

Amount of coverage (per aggregate): ________________________________________________________

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

Page 8 of 17

Professional/Peer References

Applicant Name:

 

 

List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation of your work. A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) Limit to one (1) current office associate. 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). Provide current and complete addresses. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you.

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Immune Status Information for Reappointment – Please provide immunity status by completing the question below.

DATE OF LAST PPD/MANTOUX:

Results:

Signature:

 

Date:

 

 

 

 

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

Page 9 of 17

Disclosure Questions for Reappointment Credentialing

Applicant Name:

 

 

Please provide a complete explanation if any of the following questions is answered in the affirmative. Use a separate sheet to continue, if necessary.

1.

Yes

No

In the past three years, has your professional license or registration been terminated, stipulated, restricted, limited,

 

 

 

conditioned, suspended, revoked, refused, voluntarily relinquished or not renewed by any licensing board or any

 

 

 

health-related agency organization, or is there a review pending?

 

 

 

 

 

 

 

 

 

 

2.

Yes

No

In the past three years, has your professional license or registration been investigated or is it currently being

 

 

 

investigated and, if so, what were the results?

 

 

 

 

 

 

 

 

3.

Yes

No

In the past three years, has your DEA registration been revoked, suspended, limited, or conditioned in any way, or

 

 

 

have you voluntarily relinquished your DEA registration, or is there a review pending?

 

 

 

 

 

 

 

 

4.

Yes

No

In the past three years, has your membership, participation, clinical privileges, or employment been denied,

 

 

 

terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review

organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending?

5.

Yes

No

In the past three years, have you voluntarily relinquished your membership, participation, clinical privileges or

 

 

 

request for privileges, employment, professional license, or registration in lieu of disciplinary action, or prior to or

 

 

 

during an investigation into your professional conduct or competency?

 

 

 

 

 

 

 

 

6.

Yes

No

In the past three years, have you involuntarily relinquished your membership, participation, clinical privileges or

 

 

 

request for privileges, employment, professional license or registration?

 

 

 

 

 

 

 

 

7.

Yes

No

In the past three years, has your membership or fellowship in any professional organization or your specialty board

 

 

 

certification been voluntarily or involuntarily denied, terminated, restricted, limited, suspended or revoked?

 

 

 

 

 

 

 

 

 

 

8.

Yes

No

In the past three years, have you been reprimanded, censored, or otherwise disciplined by, or have you ever been

 

 

 

subject to a corrective action agreement/plan with any licensing board, peer review organization, third party payer,

 

 

 

clinic, hospital, medical staff, or any health-related agency or organization?

 

 

 

 

 

 

 

 

 

 

9.

Yes

No

In the past three years, has your certificate or participation in any private, federal (i.e. Medicare, Medicaid, etc.) or

 

 

 

state health insurance program been revoked or otherwise limited or restricted, or is any investigation or proceeding

 

 

 

with respect to any such action presently underway?

 

 

 

 

 

 

 

 

 

 

10.

Yes

No

Are there any charges pending or are you currently charged with or have you, in the past three years, pled guilty,

 

 

 

been indicted or found guilty of a felony, gross misdemeanor, misdemeanor (other than a minor traffic violation), or other

 

 

 

offense?

 

 

 

 

 

 

 

 

 

 

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

Page 10 of 17

11.

Yes

No

In the past three years, have you been found liable, guilty or responsible for sexual impropriety or misconduct or

 

 

 

sexual harassment with a patient, co-worker, or other?

 

 

 

 

 

 

 

 

12.

Yes

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. You may be

 

 

 

asked for additional information by individual organizations.

 

 

 

 

 

 

 

 

 

 

13

Yes

No

In the past three years, has your professional liability carrier refused or canceled your coverage or excluded you

 

 

 

from performing any specific privileges within your specialty?

 

 

 

 

 

 

 

 

14.

Yes

No

In the past three years, have you practiced within your profession without professional liability insurance?

 

 

 

 

 

 

 

 

15.

Yes

No

In the past three years, have you had a physical or mental condition that would affect your ability, with or without

 

 

 

reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a

 

 

 

practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what

 

 

 

accommodations would help you provide appropriate care to patients and perform other essential functions?

 

 

 

 

 

 

 

 

 

 

16.

Yes

No

Does your use (or have you been told that your use) of alcohol or drugs affect your ability, with or without reasonable

 

 

 

accommodation, to provide appropriate care to patients and otherwise perform the essential functions in your area of

 

 

 

practice without posing a health risk to your patients? If yes, what accommodations would help you provide

 

 

 

appropriate care to patients and perform other essential functions?

 

 

 

 

 

 

 

 

 

 

17.

Yes

No

Are you currently using illegal drugs? (Currently means sufficiently recent to justify a reasonable belief that the use of

 

 

 

drugs may have an ongoing impact on ones ability to practice medicine. Illegal use of drugs refers to drugs whose

 

 

 

possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. sec. 812.22. It does not include

the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law. The term does include, however, the unlawful use of prescription controlled substances.)

Notice of Applicant’s Rights

You may review your application and information from publicly available documents at any time during the verification process. This does not include documents protected by hospital policy and/or applicable Minnesota state laws. If there are discrepancies in the information received during the process, you will be notified and allowed an opportunity to add information to your application.

To check the status of your application, go to the applicable organization website.

Attestation Signature and Date

I hereby certify that all the information on this application form is complete, true and accurate. I further agree to update this information as necessary so that it remains complete, true and accurate while my application is being processed.

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Signature _______________________________________________________ Date ________________________________

Name _________________________________________________________________________________________________

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

Page 11 of 17

Application Attestation Update

Applicant Name:

 

 

Notice of Applicant’s Rights

You may review your application and information from publicly available documents at any time during the verification process. This does not include documents protected by hospital policy and/or applicable Minnesota state laws. If there are discrepancies in the information received during the process, you will be notified and allowed an opportunity to add information to your application.

To check the status of your application, go to the applicable organization website.

The signature blocks below are to be signed ONLY if a previously

completed application is being reviewed and updated.

The application was designed so that a practitioner need complete it in its entirety only once. If application is then made to another organization which accepts this Initial Credentialing Application and it has been more than 60 days since the practitioner completed or updated the application, the practitioner may do the following:

•Review the application

•Make any needed modification

•Sign only one of the attestation blocks below, reconfirming that the application is complete, true and accurate.

Please note: It is particularly important that the Disclosure Questions be reviewed and any changes made with appropriate documentation included.

Update Attestation Signature and Date

I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate.

Signature_________________________________________________ Date_________________________

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Update Attestation Signature and Date

I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate.

Signature_________________________________________________ Date_________________________

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Update Attestation Signature and Date

I have reviewed and updated all of the information on this application, including the Disclosure Questions, and I certify it is complete, true and accurate.

Signature_________________________________________________ Date_________________________

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

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

Page 12 of 17

Authorization and Release

Applicant Name:

 

 

(Please read carefully before signing)

I understand and acknowledge that, as an applicant for membership, participation and/or clinical privileges (hereinafter, referred to as

“Participation”) athereafter referred to as Entity), it is my

responsibility to provide sufficient information upon which a proper evaluation can be undertaken of my current licensure, relevant training and/or experience, current competence, health status, character, ethics and any other criteria adopted by the Entity for Participation.

I further acknowledge that I am responsible for knowing the contents of the applicable bylaws, rules and regulations, and requirements of the Entity and its professional/medical staff/network, and agree to be bound by them in the application process and if granted Participation.

I further understand and acknowledge that the Entity, its designated agent(s) and/or other authorized representatives, including, without limitation, the Entity’s designated professional credentials verification organization (CVO), collectively referred to as “Agents”, 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 the Entity and its Agents as follows:

1.Authorization of Investigation and Release of Information Concerning Application for Participation. I authorize the Entity and its Agents to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation and authorize such third parties to release such information to the Entity and its Agents.

2.Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any health care organization at which I have applied for, currently have or had Participation or employment to release Disciplinary Information about any disciplinary action taken against me to the Entity and/or its Agents, including, without limitation, the CVO, and as otherwise may be required by law. I hereby further authorize the CVO to release Disciplinary Information about any disciplinary action taken against me to its participating entities at which I have Participation, and as otherwise may be required by law. As used herein, Disciplinary Information means information concerning (i) any action taken by such health care organizations, their administrators or their medical or other committees to revoke, deny, suspend, restrict or condition my Participation or impose a corrective action plan; (ii) any other disciplinary actions involving me including but not limited to discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges but after I have knowledge that such formal charges are contemplated and/or in preparation.

3.Release from Liability. I hereby further release from liability the Entity and its Agents, state licensing board(s), health care organizations, including, without limitation, hospitals, clinics, and third party payers, medical malpractice insurance carrier(s), and any staff, and all individuals, institutions and entities providing information in accordance with this authorization, for their acts performed in good faith and without malice in connection with the gathering and release and exchange of information as consented to above. This release shall be in addition to any other applicable immunities provided by law for peer review activities.

I understand that communication regarding my application may occur via email.

I understand and agree that this Authorization and Release is irrevocable for any period during which I am an applicant for Participation at the Entity, or I am a member of Entity’s medical or health care staff, or a participating provider of the Entity. I agree to execute another consent if law or regulation limits the application of this irrevocable authorization. Failure to promptly provide another consent may be grounds for termination or discipline of the Participant by the Entity in accordance with the applicable bylaws, rules and regulations, and requirements of the Entity.

I acknowledge that the investigation of information in this Application and the release and exchange of Disciplinary Information by the Entity and its Agents are done to achieve, maintain and improve quality patient care.

All information provided by me in the Application is true to the best of my knowledge and belief. I understand and agree that any material misstatement in or omission from the Application may constitute grounds for denial or revocation of Participation. I understand and acknowledge that the Entity shall be solely responsible for all decisions concerning the granting of Participation.

I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and Release shall be as effective as the original.

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Signature _____________________________________________________________________ Date _______________________________

Name ____________________________________________________________________________________________________________

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

Page 13 of 17

Malpractice Litigation and Professional Complaints Addendum Applicant Name:

Confidential Information

If you answered yes to disclosure question #12 on Current Disclosure question page, please complete the following form. For each lawsuit or complaint, please furnish the following and attach a copy of the complaint including your response to the complaint and level of participation. It is your responsibility to provide external verification (i.e., statement from an attorney, court records, etc.) of your response. You may choose to have your attorney complete this form. Please make additional copies of this form if needed.

Month/Year of incident: ___________________ Reported to National Practitioner Data Bank (NPDB): Yes No

Where incident occurred: Facility Name_______________________________________________________________________

Address______________________________________________ City_______________________ State________ Zip___________

Describe the nature of incident (Complaint, Allegation) - Do Not Include Patient Name or Identifiers:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Provide a narrative description of your participation/level of care:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Outcome of incident:

CONCLUDED WITH NO PAYMENTS: (month/year)

CONCLUDED WITH PAYMENTS: (month/year)

 

Dropped/Closed

Date: _______________

Verdict for plaintiff

Date: _____________

Amount $_________________

Verdict for you

Date: _______________

Settled

Date: _____________

Amount $_________________

Dismissed with prejudice*?

Date: _______________

 

 

 

PENDING:

 

 

Dismissed without prejudice**?Date: _______________

Date of filing

Date: _____________

 

 

 

 

 

 

*Dismissed with prejudice - set aside the lawsuit and deny the right to file another suit on that same claim **Dismissed without prejudice - set aside the lawsuit but leave open the possibility of another suit on the same claim

Represented by Legal Counsel for this claim/malpractice lawsuit? Yes No If yes, give the name and address of counsel.

Name: ____________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________

Phone Number: _____________________________________________________________________________________________________

Insurance company or employer that provided coverage for this claim:

Name: ____________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________

Phone Number: _________________________________________ Policy Number: ______________________________________________

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Applicant Signature___________________________________________________ Date ________________________________________

Print Name__________________________________________________________ Phone Number________________________________

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

Page 14 of 17

Chronological Employment/Practice History Addendum

Applicant Name:

 

 

 

(Please make as many extra copies as necessary)

 

 

(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: ______________________________________________________________________

Time Gaps: Explain gaps/interruptions of greater than three (3) months before, during, or after medical/professional practice

(Month, day and year required)

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

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

Page 15 of 17

Hospital Affiliation Addendum

Applicant Name:

 

 

 

 

 

 

 

(Please make as many extra copies as necessary)

 

 

 

 

(Month, day and year required)

 

 

 

 

From: _______________

Current 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 on page 5)

 

 

From: _______________

Current 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 on page 5)

 

 

From: _______________

Current 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 on page 5)

 

 

From: _______________

Current 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 on page 5)

 

 

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

Page 16 of 17

Specialty and Licensure Addendum

Applicant Name:

 

 

(Please make as many extra copies as necessary)

 

Specialty/Subspecialty Certification

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

State Licensure

License Type

State

License Number

Date Issued

Expiration Date

License Status

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

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

Page 17 of 17

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