The California Participating Physician Reapplication form is a vital document for physicians wishing to renew their participation with a healthcare organization, ensuring they continue to meet the necessary professional and regulatory standards. This comprehensive form requires the applicant to fill it out with attention to detail, using either black or blue ink, and to attach any additional sheets if more information needs to be provided than the space allows. It covers a wide array of sections including personal identifying information, practice information within the last three years, details of residencies or fellowships, current state medical license(s), board certifications, DEA Certificates, professional liability information, and current hospital and other institutional affiliations. Furthermore, it delves into the work history within the last three years, other certifications, and all other state medical licenses along with an attestation section where the reapplying physician must disclose any legal or professional issues that might affect their practice. Each section is explicitly designed to ensure the healthcare organization can thoroughly evaluate the physician's credentials, practice history, and professional standing, which is crucial for maintaining high standards of patient care and organizational compliance.
| Question | Answer |
|---|---|
| Form Name | Physician Reapplication Form |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | reapplication zip, number reapplication california, reapplication california pdf, california participating physician reapplication fill in |
CONFIDENTIAL/PROPRIETARY
California Participating Physician
Reapplication
This application is submitted to: ________________________________________, herein, this Healthcare Organization1
I. INSTRUCTIONS
This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the reapplication. Current copies of the following
documents must be submitted with this reapplication: |
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•State Medical License(s) |
•Board Certification (if applicable) within last three years |
•DEA Certificate |
•Face Sheet of Professional Liability Certification |
II. IDENTIFYING INFORMATION
Last Name:
First:
Middle:
Is there any other name under which you have been known? Name (s):
Home Mailing Address: |
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Home Telephone Number: ( |
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Home Fax Number: ( |
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Pager Number: ( |
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Birth Date: |
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Gender |
Male Female |
Social Security #: |
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Citizenship (If not a United States citizen, please include copy of Alien Registration Card):
Specialty:
Subspecialties:
III. PRACTICE INFORMATION - WITHIN LAST THREE YEARS. If nothing has changed, please check here
Practice Name (if applicable): |
Department Name (If hospital based): |
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Primary Office Street Address: |
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Telephone Number: ( |
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Office Manager/Administrator: |
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Fax Number: ( |
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Name Affiliated with Tax ID Number: |
Federal Tax ID Number: |
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Secondary Office Street Address: |
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State:
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As used in the Information Release/Acknowledgments Section of this reapplication, the term "this Healthcare Organization" shall refer to the entity to which this reapplication is submitted as identified above.
California Participating Physician Reapplication - 05/04 |
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Physician Name:
Office Manager/Administrator: |
Telephone Number: |
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Fax Number: ( |
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Name Affiliated with Tax ID Number: |
Federal Tax ID Number: |
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Tertiary Office Street Address: |
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Office Manager/Administrator: |
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Fax Number: ( |
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Name Affiliated with Tax ID Number: |
Federal Tax ID Number: |
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Other Medical Interests in Practice, Research, etc.: |
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IV. RESIDENCIES/FELLOWSHIPS - WITHIN LAST THREE YEARS. If nothing has changed, please check here
(Attach additional sheets if necessary. Reference this section number and title)
Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic), and postgraduate education completed within the last two years in chronological order, giving name, address, city and ZIP code, and dates. Include all programs you have attended, whether or not completed.
Institution:
Program Director:
Mailing Address:
City:
State:
ZIP:
Type of Training (e.g. residency, etc.):
Specialty:
From: (mm/yy)
To: (mm/yy)
Did you successfully complete the program?
Yes
No (If “No,” please explain on separate sheet.)
V. BOARD CERTIFICATION - WITHIN LAST THREE YEARS. If nothing has changed, please check here
Include certifications by board(s) which are duly organized and recognized by:
•a member board of the American Board of Medical Specialties
•a member board of the American Osteopathic Association
•a board or association with equivalent requirements approved by the Medical Board of California
•a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved postgraduate training that provides complete training in that specialty or subspecialty
Name of Issuing Board:
Specialty:
Date Certified/Recertified:
Expiration Date (if any):
Have you applied for board certification other than those indicated above?
Yes
No
If so, list board(s) and date(s):
If not certified, describe your intent for certification, if any, and date of eligibility for Certification on separate sheet.
California Participating Physician Reapplication - 05/04 |
Page 2 of 7 |
Physician Name:
VI. OTHER CERTIFICATIONS (E.G. FLUOROSCOPY, RADIOGRAPHY, ETC.) - WITHIN LAST THREE YEARS. If nothing has changed, please check here
Type:
Type:
Number: |
Expiration Date: |
Number: |
Expiration Date: |
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VII. MEDICAL LICENSURE/REGISTRATION (Remember to attach copies of documents)
California State Medical License Number |
Expiration Date: |
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Drug Enforcement Administration (DEA) Registration Number: |
Expiration Date: |
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Controlled Dangerous Substances Certificate (CDS) (if applicable): |
Expiration Date: |
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Medicare UPIN/National Physician Identifier (NPI): |
MediCal/Medicare Number: |
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VIII. ALL OTHER STATE MEDICAL LICENSES
State:
State:
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License Number: |
Expiration Date: |
License Number: |
Expiration Date: |
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IX. PROFESSIONAL LIABILITY (Remember to attach copy of professional liability policy or certification face sheet.)
Current Insurance Carrier: |
Policy #: |
Original Effective Date: |
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Per claim amount: $ |
Aggregate amount: $ |
Expiration Date: |
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Please list all of your professional liability carriers within the past two years other than the one listed above: |
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Name of Carrier: |
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California Participating Physician Reapplication - 05/04 |
Page 3 of 7 |
Physician Name:
X. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
Please list in reverse chronological order (with the current affiliation{s} first) all institutions where you have current affiliations (A) and have had previous hospital privileges (B) during the past two years. This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If you do not have hospital privileges, please explain on Addendum A.
A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference This Section Number and Title.)
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Name and Mailing Address of Primary Admitting Hospital: |
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Department/Status (active, provisional, courtesy, temporary, etc.): |
Appointment Date: |
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Name and Mailing Address of Other Hospital/Institution: |
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Department/Status: |
Appointment Date: |
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Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
Department/Status:
Appointment Date:
B. PREVIOUS HOSPITAL AND OTHER INSTITUTION AFFILIATIONS - WITHIN LAST THREE YEARS
Name and Mailing Address of Other Hospital/Institution: |
City: |
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State: |
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From: (mm/yy) |
To: (mm/yy) |
Reason for leaving: |
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Name and Mailing Address of Other Hospital/Institution: |
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From: (mm/yy) |
To: (mm/yy) |
Reason for leaving: |
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XI. WORK HISTORY - WITHIN LAST THREE YEARS. If nothing has changed, please check here
Chronologically list all work history activities within the last three years (use extra sheets if necessary). This information must be complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional work history on a separate page.
Current Practice:
Contact Name:
Telephone Number: ( |
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Fax Number: ( |
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Mailing Address:
City:
State:
ZIP:
Name of Practice /Employer:
Contact Name:
Telephone Number: ( |
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Fax Number: ( |
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Mailing Address:
City:
State:
ZIP:
California Participating Physician Reapplication - 05/04 |
Page 4 of 7 |
Physician Name:
XII. ATTESTATION QUESTIONS
Please answer the following questions "yes" or "no." If your answer to questions A through K is "yes," or if your answer to L is “no,” please provide full details on separate sheet.
A.Has your license to practice medicine in any jurisdiction, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of reprimand or is such action pending?
Yes |
No |
B.Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you voluntarily or involuntarily relinquished eligibility to provide services or accepted conditions on your eligibility to provide services, for reasons relating to possible incompetence or improper professional conduct, or breach of contract or program conditions, by Medicare, Medicaid, or any public program, or is any such action pending?
Yes |
No |
C. Have your clinical privileges, membership, contractual participation or employment by any medical |
organization (e.g. hospital medical staff, medical group, |
independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system), ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach of contract, or is any such action pending?
Yes |
No |
D.Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from any medical organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), medical society, professional association, medical school faculty position or other health delivery entity or system) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending?
Yes |
No |
E.Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program?
Yes |
No |
F.Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or not renewed , or is any such action pending?
Yes |
No |
G.Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing from eligible to certified)?
Yes
H. Have you ever been convicted of any crime (other than a minor traffic violation)?
No
Yes
I. Do you presently use any drugs illegally?
No
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No |
J.Have any judgments been entered against you, or settlements been agreed to by you within the last seven (3) years, in professional liability cases, or are there any filed and served professional liability lawsuits/arbitrations against you pending?
Yes |
No |
K.Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures?
YesNo
L.Are you able to perform all the services required by your agreement with, or the professional staff bylaws of, the Healthcare Organization to which you are applying, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients?
Yes |
No |
I hereby affirm that the information submitted in this Section XVI, Attestation Questions, and any addenda thereto is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material, omissions or misrepresentations may result in denial of my reapplication or termination of my privileges, employment or physician participation agreement.
Print Name Here:
Physician Signature________________________________________________________________________________ Date:
(Stamped Signature Is Not Acceptable)
California Participating Physician Reapplication - 05/04 |
Page 5 of 7 |
Physician Name:
INFORMATION RELEASE/ACKNOWLEDGMENTS
I hereby consent to the disclosure, inspection and copying of information and documents relating to my credentials, qualifications and performance ("credentialing information") by and between "this Healthcare Organization” and other Healthcare Organizations (e.g., hospital medical staffs, medical groups, independent practice associations {IPAs}, health plans, health maintenance organizations {HMOs}, preferred provider organizations {PPOs}, other health delivery systems or entities, medical societies, professional associations, medical school faculty positions, training programs, professional liability insurance companies {with respect to certification of coverage and claims history}, licensing authorities, and businesses and individuals acting as their agents (collectively, "Healthcare Organizations"), for the purpose of evaluating this credentialing reapplication and any credentialing application regarding my professional training, experience, character, conduct and judgment, ethics, and ability to work with others. In this regard, the utmost care shall be taken to safeguard the privacy of patients and the confidentiality of patient records, and to protect credentialing information from being further disclosed.
I am informed and acknowledge that federal and state2 laws provide immunity protections to certain individuals and entities for their acts and/or communications in connection with evaluating the qualifications of healthcare providers. I hereby release all persons and entities, including this Healthcare Organization, engaged in quality assessment, peer review and credentialing on behalf of this Healthcare Organization, and all persons and entities providing credentialing information to such representatives of this Healthcare Organization, from any liability they might incur for their acts and/or communications in connection with evaluation of my qualifications for participation in this Healthcare Organization, to the extent that those acts and/or communications are protected by state or federal law.
I understand that I shall be afforded such fair procedures with respect to my participation in this Healthcare Organization as may be required by state and federal law and regulation, including but not limited to, California Business and Professions Code Section 809 et seq, if applicable.
I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications.
During such time as this reapplication is being processed, I agree to update the reapplication should there be any change in the information provided.
In addition to any notice required by any contract with a Healthcare Organization, I agree to notify this Healthcare Organization immediately in writing of the occurrence of any of the following: (i) the unstayed suspension, revocation or no renewal of my license to practice medicine in California; (ii) any suspension, revocation or no renewal of my DEA or other controlled substances registration; or (iii) any cancellation or no renewal of my professional liability insurance coverage.
I further agree to notify this Healthcare Organization in writing, promptly and no later than fourteen (14) calendar days from the occurrence of any of the following: (i) receipt of written notice of any adverse action against me by the Medical Board of California taken or pending, including but not limited to, any accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to practice medicine; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a Section 805 report with the Medical Board of California, or a report with the National Practitioner Data Bank; or (iii) the denial, revocation, suspension, reduction, limitation, no renewal or voluntary relinquishment by resignation of my medical staff membership or clinical privileges at any Healthcare Organization; or (iv) any material reduction in my professional liability insurance coverage; or (v) my receipt of written notice of any legal action against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including, but not limited to, fraud and abuse proceedings or convictions.
I hereby affirm that the information submitted in this reapplication and any addenda thereto (including my curriculum vitae if attached) is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material omissions or misrepresentations may result in denial of my reapplication or termination of my privileges, employment or physician participation agreement. A photocopy of this document shall be as effective as the original, however, current dates are required on pages 5 and 6.
Print Name Here _
Physician Signature__________________________________________________________________________________Date:
(Stamped Signature Is Not Acceptable)
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The intent of this release is to apply at minimum, protections comparable to those available in California to any action, regardless of where such action is brought.
California Participating Physician Reapplication - 05/04 |
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Physician Name:
Addenda Submitting (Please check the following): |
This Reapplication and Addenda A and B were created and are |
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endorsed by: |
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Addendum A - Health Plan and IPA/Medical Group |
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American Medical Group Association - |
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Addendum B - Professional Liability Action Explanation |
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California Association of Health Plans - |
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California Healthcare Association - |
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California Medical Association - |
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Individual healthcare organizations may request additional information or attach supplements to this form. They are not part of the California Participation Physician Reapplication nor have they been endorsed by the above organizations. Any questions about supplements should be addressed to the health care organization from which it was provided.
California Participating Physician Reapplication - 05/04 |
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Physician Name: