Uniform Healthcare Practitioner Credentialing Application Form – Fill Out and Use This PDF

GEORGIA UNIFORM HEALTHCARE PRACTITIONER CREDENTIALING APPLICATION FORM

Please contact the Hospital, Health Plan or other Healthcare Organization, hereinafter "Healthcare Entity(ies)", to which you are applying for instructions on how to proceed. The Healthcare Entity may not have adopted this form for use and/or may require a pre- application prior to submitting this form.

This Application has been designed and organized into two main parts: Part One and Part Two.

Part One is standardized for Healthcare Entity(ies), and contains identical questions that Healthcare Entities need to ask as a part of their credentialing processes. Part One is available on the Georgia Uniform Healthcare Practitioner Credentialing Application Form (UHPCAF) web site at www.georgiacredentialing.org.

Part Two for health plans is standardized and contains additional identical questions that health plans need to ask as part of their credentialing processes and, is also available at www.georgiacredentialing.org.

Part Two for hospitals contains additional, customized or more specific questions as part of their credentialing and privileging processes.

PREPARED AND ENDORSED BY MEMBERS OF:

GHA/AN ASSOCIATION OF HOSPITALS AND HEALTH SYSTEMS

GEORGIA IN-HOUSE COUNSEL ASSOCIATION

GEORGIA ASSOCIATION MEDICAL STAFF SERVICES

GEORGIA ASSOCIATION OF HEALTH PLANS

GEORGIA UNIFORM HEALTHCARE PRACTITIONER

CREDENTIALING APPLICATION FORM

Prior to completing this Application, please read and observe the following:

GENERAL INSTRUCTIONS

•Please type or print legibly your responses.

•Please note that modification to the wording or format of this Application will invalidate it.

•All information requested must be FULLY and TRUTHFULLY provided.

•Any changes to your responses must be lined through and initialed. Use of any form of correctional fluid or tape is not acceptable.

•If an entire section does not apply to you, then please check the box provided at the top of the section. If a particular question does not apply to you, then write “N/A” in the answer blank. If there are multiple, repetitive answer blanks in a particular section (as, for example, in the section entitled “Residencies and Fellowships”), it is not necessary to mark “N/A” in each unneeded answer blank.

•Unless specifically permitted by a particular question, please understand that a reference to “See CV” for an answer is not appropriate.

•If more space than is provided on this Application is needed in order to answer a question completely, use the attached Explanation Form as necessary. Make as many copies of the Explanation Form as needed to fully answer each question. Include the section and page number of the question being answered as well as your name and Social Security Number on each Explanation Form. Attach all Explanation Forms to this Application.

•After Part One of the Application has been completed in its entirety but before you sign and date it or fill in the information on page ii, make a copy of the Application to retain in your files and/or computer for future use.

In so doing, at the time of a submission to another Healthcare Entity, all you will need to do is to check to ensure that all the information remains complete, current and accurate before completing page ii and signing and forwarding the Application as needed.

•Any gaps of time greater than thirty (30) days from completion of medical school to the present date must be accounted for before your Application will be considered complete.

•Please sign and date the Application.

•Please sign and date Schedule A, Schedule B and Schedule C (as appropriate).

•Identify the Healthcare Entity to which you are submitting this Application and for what practice area(s) you are applying in the spaces provided on page ii.

•Mail the Application, Schedules, any Explanation Form(s) prepared in order to answer any question(s) completely, as well as a copy of all applicable enclosures listed on page ii to the Healthcare Entity.

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GENERAL INSTRUCTIONS - continued

A current copy of the following documents must be submitted with your Application:

•One recent passport size photograph of yourself

•State Professional License(s)

•Federal Narcotics License (DEA Registration)

•Curriculum Vitae with complete professional history in chronological order (month & year)

•Diplomas and/or certificates of completion (e.g. medical school, internship, residency, fellowship, etc.)

•Diplomate of National Board of Medical Examiners or Educational Commission for Foreign Medical Graduates (ECFMG) Certificate (if applicable)

•Specialty/Subspecialty Board Certification or letter from Board(s) stating your status (if applicable)

•Declaration Page (Face Sheet) of Professional Liability Policy or Certificate of Insurance

•Permanent Resident Card or Visa Status (if applicable)

•Military Discharge Record (Form DD-214) (if applicable)

Name of Healthcare Entity to which you are submitting this Application:

For what type of relationship (i.e., staff membership, network participation, etc.):

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II.	PRACTICE INFORMATION - continued									Does Not Apply
NAME OF SECONDARY CLINICAL PRACTICE:						Type of Practice Setting:				Specialty:
							Solo			Group/Multi-Specialty
							Group/Single			Hospital Based
										Other
Secondary Clinical Practice Street Address:						Start Date at Location (mm/yy):				/
City:		County:			State:				Zip:
Answering Service Number: ( )		-	Pager/Beeper Number: (			)	-		Office E-Mail Address:
										@
Federal Tax ID Number for this Practice Address:						Name Affiliated with Tax ID Number:
B. OTHER OFFICES: Please list any other current office locations with the above information on Explanation Form(s).
C. BILLING ADDRESS: If different than primary clinical site address, please provide complete billing address:
Name of Office Manager/Administrative Contact:			Office Phone Number:						Office Fax Number:
			( )	-					( )	-

D. INTENTION: If you are not currently in practice, please describe your intentions regarding beginning and/or reinstating your practice.

E. CORRESPONDENCE: To what address would you like all correspondence forwarded?

Primary Office

Secondary Office

Billing Office

Home

Other (Please specify)

F. LANGUAGES:

1. Please list any language other than English (including sign language) in which you are fluent:

2. Please list any language other than English (including sign language) in which a member of your staff is fluent and identify staff member:

III. BOARD CERTIFICATION/RECERTIFICATION

Are you board certified?	YES	NO List all current and past board certifications.
			Date Certified	Date Recertified	Date Recertified	Expiration
Name of Issuing Board		Specialty	(mm/yy):	(mm/yy):	(mm/yy):	Date
						(if any)
						(mm/yy):
			/	/	/	/
			/	/	/	/
			/	/	/	/

Please answer the following questions. Attach Explanation Form(s), if necessary.

	A.	Have you ever been examined by any specialty board, but failed to pass? If yes, please provide name of board(s)			YES	NO
		and date(s):
		1.	If you are not currently certified, have you applied for the certification examination?		YES	NO
	B.	2.	If you have not applied for the certification examination, do you intend to apply for the certification		YES	NO
		examination? If yes, when? Date:		/
		3.	If you have applied for the certification examination, have you been accepted to take the certification		YES	NO
		examination?
		4.	If you have been accepted, when do you intend to take the certification examination?		Date:	/
		5.	If you do not intend to apply for the certification examination, please attach reason on Explanation Form(s)

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