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

Please type or print legibly your responses.

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, check the box provided at the top of the section. If a particular question does not apply to you, write "N/A" in the answer blank. If there are multiple, repetitive answer blanks in a particular section, it is not necessary to mark "N/A" in each unneeded answer blank.

Unless specifically permitted by a particular question, 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.

Page ii of the 06/01/2006 Georgia Uniform Healthcare Practitioner Initial Credentialing Application Form: 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), and 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), and Military Discharge Record (Form DD-214) (if applicable).

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. 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.

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.

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.

A curriculum vitae is not sufficient for a complete answer to these questions.

Please list in reverse chronological order all work and professional and practice history activities not detailed under Section II, IV or VI. Include any previous office addresses and any military experience. Explain any gaps greater than thirty (30) days.

If your training, practice, military or work experience has been interrupted for more than thirty (30) days by, for example, illness, injury or family medical leave, then please explain any such gap since completing medical school.

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 list three (3) references, from licensed professional peers who through recent observations have personal knowledge of and are directly familiar with your professional competence, conduct and work. Do not include relatives. At least one reference must be a practitioner in your same professional discipline.

Please refer to Part Two of this Application for any additional specific reference requirements.

This section to be completed by the Practitioner. Modification to the wording or format of these Attestation Questions will invalidate the Application.

Please answer the questions "yes" or "no". If your answer to any of the following questions is "yes", please provide details and reasons, as specified in each question, on an Explanation Form and attach to the Application.

This attestation statement and Application must be signed no more than 180 days prior to the credentialing decision date.

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

By signing this Application, you certify, agree, understand and acknowledge that the information in this entire Application, including all subparts and attachments, is complete, current, correct, and not misleading.

Any misstatements or omissions (whether intentional or unintentional) on this Application may constitute cause for denial of my Application or summary dismissal or termination of my clinical privileges, membership or practitioner participation agreement.

No action will be taken on this Application until it is complete and all outstanding questions with respect to the Application have been resolved.

Page 14 of the 06/01/2006 Georgia Uniform Healthcare Practitioner Initial Credentialing Application Form is Schedule B, the Professional Liability Claims Information Form. The following information is necessary to complete the credentialing verification process and will be kept confidential.

Please print or type answers for any malpractice claims reported to your malpractice insurance carrier, opened, closed, settled or paid. For initial credentialing, please complete a separate form for each claim; for recredentialing, complete forms only for new/changed status claims since your last recredentialing. One case per sheet (please photocopy if additional sheets are needed).

Signature is required even if Does Not Apply is checked.

By signing, you certify that the information contained in this form is correct and complete (even if N/A) to the best of your knowledge.