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State of West Virginia

Credentialing Form

Please complete each section thoroughly.

Attach additional sheets where necessary.

(Indicate clearly the practitioner name and section on each attachment)

Type or print clearly in black ink.

Sign and date the application.

Practitioner’s Name

Date

Social Security Number

Date of Birth

Credentialing Entity Name

YOU MUST INCLUDE THE FOLLOWING WITH THIS

COMPLETED APPLICATION

(Use this checklist as a guide)

Copy of ALL current State License(s): For purposes of this application, State License shall include licensure from all 50 states, the District of Columbia, and U.S. Territories.

Copy of current DEA Registration (if applicable)

Copy of current State Controlled Dangerous Substance (CDS) Certificate (if applicable)

Copy of current professional liability insurance policy face sheet, showing expiration dates, limits, and Practitioner’s name

Copy of Board Certification Certificate(s) (if applicable), or other National Certification Certificates Copy of certificate(s) or letter(s) certifying formal post-graduate training

Copy of Curriculum Vitae/Resume (Include work history)

(Not accepted as a substitute for completion of application.)

Copy of ECFMG Certificate (if applicable)

Copy of W-9 for verification of each tax identification number used (required for payers only)

Copy of Visa or work permit (if not a U.S. citizen)

Copies of CME/CEU session certificates (if required by Credentialing Entity)

Signature requirements per each entity

Professional Peer References (if required by Credentialing Entity)

CREDENTIALING ENTITIES MAY SUPPLEMENT THIS CHECKLIST OF REQUIRED ITEMS AS NEEDED TO MEET CREDENTIALING REQUIREMENTS.

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**Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 1

State of West Virginia

Credentialing Form

Responses must be legible. Any response, which cannot be completed in the space provided, may be included on supplementary sheets of paper and attached. DO NOT LEAVE ANY FIELDS BLANK. If an item is not applicable, indicate N/A. Please note you will be held responsible for all information or omissions in this application, regardless of whether such statements were prepared by you, an employee, agent or representative. For time gaps greater than three (3) months provide information in Section 11. After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.

Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment. (If more space is needed, please supply the information on a separate sheet and attach.)

1. Applicant Information

Last Name		First Name	Middle Name	Maiden Name	Suffix
(as shown on state license)		First Name	Middle Name	Maiden Name	(e.g., Jr., Sr., etc.)
(as shown on state license)					(e.g., Jr., Sr., etc.)

Degree (e.g., MD, DO, DDS,		Gender	Birth Date	Birthplace
DPM, PA-C, RN)		Gender	Birth Date	Birthplace
DPM, PA-C, RN)
	Male	Female

Other Name(s) Also Known By

Name(s)

Name:

Date Name Used

From:

To:

From:

To:

Area(s) of Specialty (please be specific and list any primary focus)

Specialty:

Sub-specialty:

Citizenship

Are you a US Citizen?

Yes

If no, what is your citizenship?

Please provide the following

If no, what is status of your Visa?

information if you are not a

If no, do you hold a permanent work permit?

US Citizen:

Type of Visa:

Expiration of Visa:

Social Security #

National Provider ID # (if

ECFMG # (if applicable,

ECFMG Certificate Date

available)

attach copy)

Current Home Address

City

State

Zip Code

Home Telephone

Is this # unlisted?

Home Fax

(

)

Yes

(

)

Language(s) Spoken (other than English)

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**Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 2

State of West Virginia Credentialing Form: Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment. (If more space is needed, please supply the information on a separate sheet and attach.)

2. Office Practice Information

If you have more than one office site or more than one billing address or entity, please make a photocopy of this section before completing it and provide information for each site or billing entity (i.e., multiple tax identifiers), as needed. Indicate below whether the office is the primary or an additional site. (NOTE: Only one primary site should be designated.)

Primary Office Site # 1

Additional Office Site #

Group/Practice Name

Individual

Hospital Based

Partnership

Type of Practice

Teaching or Research

Group

Other (specify):

Corporation

Address (Building, Street, Suite #)

City

State

Zip Code

County

Telephone Number

Fax Number

Answering Service/After-Hours Number

(

)

(

)

(

)

Alternate Telephone Number

Cell Phone Number

Beeper/Pager Number

(

)

(

)

(

)

E-Mail Address

Long Range Beeper Number

(

)

Medicare Number

UPIN Number

Medicaid Number

Are you currently accepting new patients?

Have you closed your practice to any plans or programs?

Yes

By referral only

Yes

If Yes, please list:

Handicap Accessible?

Public Transit Available?

Yes

Does the office have other services available for disabled?

If yes, list below what services are available

(TTY, ASI, Mental/physical impairments, etc.)

Yes

Office Manager’s Name

Nurse Manager’s Name

Credentialing Contact

N/A

Name

N/A

Phone #

Office Hours ______

Check if not applicable

Check if

practitioner is not available to see patient during hours indicated

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Services Provided

(Please check below if these services are available)

Lab Services

On-Site

Reference Lab Name:

CLIA Number and Type of Certification:

Radiology Services

EKG

Sigmoidoscopy

Audiology Services

Treadmill

Other (Please list):

List any special diagnostic or treatment procedures performed in your office:

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Patient Population

Do you limit the age of patients you treat?

If yes, what ages do you treat?

Yes

Minimum:

Maximum:

Remittance/Billing Information

(NOTE: Must match box 33 on HCFA/CMS 1500)

Are all services payable to one practice or group

Yes

name/address?

Group/Practice Name (Check Payable To):

Address (Building, Street, Suite #)

City

State

Zip Code

Billing Office Phone Number

Billing Manager’s Name

(

)

Tax ID Number (must match W-9)

Name affiliated with Tax ID Number (must match W-9)

Business Interests

Do you or your business entity own, operate,

Yes

have an interest in, or participate in any medical

If yes, provide details on separate sheet.

enterprise or business?

Do you have a financial relationship with a

hospital, clinical lab, nursing home, pharmacy,

Yes

radiology lab, emergency room, or any other

If yes, provide details on separate sheet.

medical related organization?

Practice Classification

Primary Care Physician (Family Practitioners, Internists, or Pediatricians who deliver primary health care services) Specialist Physician (Physicians other than primary care physicians in their designated clinical practice)

Allied Health Professional (Licensed, certified, or registered non-physician Practitioners of direct patient care services) Dual Role (Serve as both a Primary Care Physician as well as a Specialist)

Directory Listing

Should this office be listed in the directory?		Should this office receive correspondence?

Yes	No	Yes	No

Please indicate, in preference order, how you wish to be listed in the directory.

Primary Specialty:

Secondary Specialty:

		After-Hours Coverage
Do you provide 24-hour coverage?				Describe Coverage

Yes	No	NA

Do you have an answering service/machine?			Is your answering service/machine available
Do you have an answering service/machine?			at all times when you are not in the office?
			at all times when you are not in the office?
Yes	No	NA	Yes	No	NA

List below other after-hours arrangements or special instructions to patients for after-hours care needs:

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Back-up Coverage

(Please list the name, specialty, and phone number of partner(s) or associate(s)

or physician(s) covering your practice in your absence.)

Name

Specialty

Partner, Associate,

Phone Number

Or Covering

(

)

(

)

(

)

(

)

Admitting Service

Do you admit patients to the hospital under your own service?

If no, to whom do you admit?

Yes

Practitioner Extenders

Please check any of the following practitioner extender types and list

individual names who you either employ or utilize for direct patient care.

Physician’s Assistant:

Nurse Practitioner:

Nurse Midwife:

Other (specify):

Workers’ Compensation Information

Do you accept Workers’ Compensation Patients?

Yes

a. Are staff trained in identification and care of patients with work-related

illness/injury and provide care/services with an active return to work

philosophy?

Yes

b. Modified or alternative duty is actively evaluated for each Workers’

Compensation claimant.

Yes

If yes, please provide the following information:

c. Office will accommodate urgent walk-ins (or non-urgent appointments within

48 hours) to treat injured or ill workers and facilitate their return to work, if

possible.

Yes

d. Staff are available and willing to provide compensation representatives

information regarding a claimant’s care.

Yes

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3. Medical/Professional Education:

(Attach copy of diploma. If international graduate, submit ECFMG Certificate.)					If additional space is needed, please
photocopy this page and attach. All time gaps greater than three (3) months must be accounted for in Section 11.
Name of School		Degree Received				Dates of Attendance (List Mo/Yr)

				From:			To:

Street Address		Phone # (if known)		Fax # (if known)			Graduation Date
	(	)	-	(	)	-

City			State			Country	Zip Code


Name of School		Degree Received				Dates of Attendance (List Mo/Yr)

				From:			To:

Street Address	Telephone # (if known)			Fax # (if known)			Graduation Date
	(	)	-	(	)	-

City			State			Country	Zip Code

Professional Training - Internship/Residency/Fellowship/Preceptorship/Other

List all, completed or not. (Attach copies of all program certificates.)

All time gaps greater than three (3) months must be

accounted for in Section 11.

Training Institution

Program

Internship

Fellowship

Other:

Residency

Preceptorship

Street Address

City

State

Country

Zip Code

Telephone # (if known)

Fax # (if known)

(

)

(

)

Type of Training/Specialty

Dates of Training (Mo/Yr)

Was program successfully completed?

From:

To:

Yes

If no, explain:

Your Program Director’s Name

Current Program Director’s Name (if known)

Training Institution

Program

Internship

Fellowship

Other:

Residency

Preceptorship

Street Address

City

State

Country

Zip Code

Telephone # (if known)

Fax # (if known)

(

)

(

)

Type of Training/Specialty

Dates of Training (Mo/Yr)

Was program successfully completed?

From:

To:

Yes

If no, explain:

Your Program Director’s Name

Current Program Director’s Name (if known)

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		Training Institution					Program
					Internship		Fellowship	Other:
					Residency		Preceptorship

		Street Address					City


		State	Country				Zip Code


		Telephone # (if known)					Fax # (if known)

(	)	-		(	)	-

		Type of Training/Specialty	Dates of Training (Mo/Yr)				Was program successfully completed?

							Yes	No
							If no, explain:

		Your Program Director’s Name			Current Program Director’s Name (if known)


		Training Institution					Program
					Internship		Fellowship	Other:
					Residency		Preceptorship

		Street Address					City


		State	Country				Zip Code


		Telephone # (if known)					Fax # (if known)

(	)	-		(	)	-

		Type of Training/Specialty	Dates of Training (Mo/Yr)				Was program successfully completed?

							Yes	No
							If no, explain:

		Your Program Director’s Name			Current Program Director’s Name (if known)

5. State License(s): List all current and past professional licenses (Submit copy of current licenses)

State

License #

Issue Date

Expiration Date

Status

Is/was license

Reason License is/was

(Please check)

restricted?

Inactive or Restricted

Active

Yes

Inactive

Active

Yes

Inactive

Active

Yes

Inactive

Active

Yes

Inactive

Active

Yes

Inactive

Does the scope of your practice require the supervision of

Yes

another practitioner?

If Yes, please list name of each supervising practitioner:

Practitioner Name:

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6. Certifications/Registrations

Check here if entire section is not applicable to applicant.

	Federal DEA Certificate
	Not applicable
	(Submit copy of current DEA Certificate)
Certificate #	Expiration			Unlimited?
	Date			Unlimited?
	Date

		Yes	No	If no, explain:

State DEA or CDS Certificate(s)

Not applicable

(Submit copy of current State Controlled Dangerous Substance Certificates, if applicable)

Certificate #	Expiration			Unlimited?
	Date			Unlimited?
	Date
		Yes	No	If no, explain:

Other Certificate(s)/Formal Training

(Please check below if currently certified. Submit copy(s))

Basic Life Support (BLS)

Advanced Cardiac Life Support (ACLS)

Pediatric Advanced Life Support (PALS)

Advanced Trauma Life Support (ATLS)

Neonatal Advanced Life Support (NALS)

Anesthesia Permit

Health Care Practitioner (Core C)

Neonatal Resuscitation Program (NRP)

Therapeutics Classification Number (Optometrists only)

Other (please list below or on a separate sheet and include descriptions):

7.Specialty Board Certification: Submit copies of board certifications and/or qualification confirmation letter.

Check here if entire section is not applicable to applicant.

Are you board certified?

Yes

No	(If yes, list below)

Certifying Board Name & Specialty	Initial Certification Date	Most Recent	Next Expiration
Certifying Board Name & Specialty	Initial Certification Date	Recertification Date	Date
		Recertification Date	Date


If not certified, are you qualified to sit for the examination?	Yes		No

	Failed to pass specialty board examination
		How many times have you taken the exam but failed
		to pass?
		Last date(s) exam was taken:			___________
If not certified, please indicate your status in the certifying	Date(s) board examination was taken/retaken and date board
	exam is scheduled, if applicable:
process:	Date(s) taken/retaken:			_______________________
	Date(s) taken/retaken:			_______________________
	Date scheduled, if applicable:				_________________

	Not eligible to take specialty boards
	Not planning to take specialty boards
	Admissible with exam pending

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8.Professional Peer References

Please list three (3) professional peer references who have personal knowledge of your current clinical abilities, ethical character, health status, and ability to work cooperatively with others, and who will provide specific written comments on these and other relevant matters upon request. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. These individuals must have acquired the requisite knowledge through observation of your professional practice over a reasonable period of time. At least one reference must be from the same specialty area, not formerly, currently or about to become associated with you in practice. At least one must be from an individual who has had organizational responsibility in a medical setting (e.g., Department Chair, Medical Director). If your training was completed within the past three (3) years, you may list your Program Director(s) as a professional reference. If you have been out of training for more than three (3) years, it is important to name individuals who are more currently familiar with your professional practice. The individuals should not be related to you by family or financial association.

		Reference Name 1					Title

		Street Address			City		State	Zip


		Telephone Number				Fax Number (if known)

(	)	-	(	)	-

		Relationship:
(instructor, department chair, chief of staff, colleague, etc.)
		Reference Name 2					Title

		Street Address			City		State	Zip


		Telephone Number				Fax Number (if known)

(	)	-	(	)	-

		Relationship:
(instructor, department chair, chief of staff, colleague, etc.)
		Reference Name 3					Title

		Street Address			City		State	Zip


		Telephone Number				Fax Number (if known)

(	)	-	(	)	-

		Relationship:
(instructor, department chair, chief of staff, colleague, etc.)

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Page 9

9.Hospital/Health Care Entity Affiliations (list current affiliation first)

Check here if entire section is not applicable to applicant.

List ALL health care facilities at which you currently have, or have had, privileges. Explain gaps greater than three (3) months in

Section 11.

	Name of Current Primary Hospital Affiliation				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)

		Street Address			City		State	Zip


	Telephone Number					Fax Number

(		)	-	(		)	-

	Department/Service				Department Chair’s Name


		Staff Status			# Admits/Month		Percent of time spent at facility


		Restricted?			Dates of Affiliation (Mo/Yr)

		Yes	No		From:		To:
	If yes, explain:				From:		To:
	If yes, explain:

			Reason for leaving, if applicable


	Name of Affiliation/Hospital/Healthcare Entity				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)

		Street Address			City		State	Zip


	Telephone Number					Fax Number

(		)	-	(		)	-

	Department/Service				Department Chair’s Name


		Staff Status			# Admits/Month		Percent of time spent at facility


		Restricted?			Dates of Affiliation (Mo/Yr)

		Yes	No		From:		To:
	If yes, explain:				From:		To:
	If yes, explain:

			Reason for leaving, if applicable


	Name of Affiliation/Hospital/Healthcare Entity				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)

		Street Address			City		State	Zip


	Telephone Number					Fax Number

(		)	-	(		)	-

	Department/Service				Department Chair’s Name

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Staff Status			# Admits/Month	Percent of time spent at facility


Restricted?			Dates of Affiliation (Mo/Yr)

Yes	No		From:	To:
If yes, explain:			From:	To:
If yes, explain:

		Reason for leaving, if applicable

9.Additional Affiliations:

(Photocopy this page for additional affiliations)

	Name of Affiliation/Hospital/Healthcare Entity				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)


		Street Address			City		State	Zip


	Telephone Number					Fax Number

(		)	-	(		)	-

	Department/Service				Department Chair’s Name


		Staff Status			# Admits/Month		Percent of time spent at facility


		Restricted?			Dates of Affiliation (Mo/Yr)

		Yes	No		From:		To:
	If yes, explain:				From:		To:
	If yes, explain:

			Reason for leaving, if applicable


	Name of Affiliation/Hospital/Healthcare Entity				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)


		Street Address			City		State	Zip


	Telephone Number					Fax Number

(		)	-	(		)	-

	Department/Service				Department Chair’s Name


		Staff Status			# Admits/Month		Percent of time spent at facility


		Restricted?			Dates of Affiliation (Mo/Yr)

		Yes	No		From:		To:
	If yes, explain:				From:		To:
	If yes, explain:

			Reason for leaving, if applicable


	Name of Affiliation/Hospital/Healthcare Entity				Type of Hospital/Health Care Entity		(e.g., Hospital, Nursing Home, etc.)


		Street Address			City		State	Zip

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Page 11


Telephone Number					Fax Number

(	)	-		(	)	-

Department/Service				Department Chair’s Name


	Staff Status			# Admits/Month		Percent of time spent at facility


	Restricted?			Dates of Affiliation (Mo/Yr)

	Yes	No		From:		To:
If yes, explain:				From:		To:
If yes, explain:

			Reason for leaving, if applicable

10. Work History/Experience:

List in chronological order (beginning with current) all current and previous professional work history including Military Service. You must explain gaps greater than three (3) months in Section 11. (If additional space is needed, please photocopy this page and attach.)

Practice/Employer					Contact Name

	Street Address			City		State	Zip


Telephone Number				Fax Number (if known)

(	)	-		(	)	-

Dates of Employment (Month/Year)				Job Title or Type of Work Performed

From:		To:

			Reason for leaving, if applicable


Practice/Employer					Contact Name

	Street Address			City		State	Zip


Telephone Number				Fax Number (if known)

(	)	-		(	)	-

Dates of Employment (Month/Year)				Job Title or Type of Work Performed

From:		To:

			Reason for leaving, if applicable


Practice/Employer					Contact Name

	Street Address			City		State	Zip


Telephone Number				Fax Number (if known)

(	)	-		(	)	-

Dates of Employment (Month/Year)				Job Title or Type of Work Performed

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Page 12

From:		To:

			Reason for leaving, if applicable


Practice/Employer					Contact Name

	Street Address			City		State	Zip


Telephone Number				Fax Number (if known)

(	)	-		(	)	-

Dates of Employment (Month/Year)				Job Title or Type of Work Performed

From:		To:

Reason for leaving, if applicable

11. Time Gaps

Provide information for all time frames of three (3) months or more that are not covered in Medical/Professional Education, Professional Training, Hospital/Health Care Entity Affiliations, or Work History/Experience sections (such as extended travel, maternity leave, relocation, etc.).

Check here if entire section is not applicable to applicant.

Section	Dates	Explanation
	From:
	To:

Medical/Professional	From:
Education	To:

	From:
	To:

	From:
	To:

Professional Training	From:
Professional Training	To:
	To:

	From:
	To:

	From:
	To:

Hospital/Health Care Entity	From:
Affiliations	To:

	From:
	To:

	From:
	To:

Work History/Experience	From:
Work History/Experience	To:
	To:

	From:
	To:

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Page 13

12.Continuing Education Requirements

Check here if entire section is not applicable to applicant.

A.Have you completed the continuing education hours as required by your State Licensing

Board during the past two (2) years OR the required CME/CEU hours (if applicable) from	Yes
the State licensing board in which you are currently practicing?

B.Attach certificates as noted on Page 1 for the CME/CEU sessions you have completed in last two (2) years (if required by Credentialing Entity).

13.Professional Associations/Organizations

List the associations/organizations related to your profession in which you are a member. Please include dates of affiliations. Include faculty appointments.

Check here if not applicable

Professional Association/Organization

Dates of Affiliation

From:To:

Professional Association/Organization

Dates of Affiliation

From:To:

Professional Association/Organization

Dates of Affiliation

From:To:

Professional Association/Organization

Dates of Affiliation

From:To:

Professional Association/Organization

Dates of Affiliation

From:To:

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Page 14

14.Professional Liability Insurance Coverage:

Submit a copy of your current professional liability insurance coverage face sheet showing coverage in your practice specialty. Please list current and previous insurance carriers for the last ten (10) years in chronological order beginning with most current. (If additional space is needed, please photocopy this page and attach.)

Current Insurance Carrier

Telephone Number

(

)

Address

City

State

Zip

Coverage

Amount of Coverage

If Umbrella/Excess coverage,

Effective Date

Termination Date

amount of coverage

million/occurrence

million/aggregate

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made

Occurrence

Yes

Second Current Insurance Carrier

Telephone Number

(

)

Address

City

State

Zip

Coverage

Amount of Coverage

If Umbrella/Excess coverage,

Effective Date

Termination Date

amount of coverage

million/occurrence

million/aggregate

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made

Occurrence

Yes

Previous Insurance Carrier

Telephone Number

(

)

Address

City

State

Zip

Coverage

Amount of Coverage

If Umbrella/Excess coverage,

Effective Date

Termination Date

amount of coverage

million/occurrence

million/aggregate

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made

Occurrence

Yes

Previous Insurance Carrier

Telephone Number

(

)

Address

City

State

Zip

Coverage

Amount of Coverage

If Umbrella/Excess coverage,

Effective Date

Termination Date

amount of coverage

million/occurrence

million/aggregate

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made

Occurrence

Yes

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Page 15

15.Professional Liability Insurance Coverage Disclosure:

If the answer to any of these questions is yes, please provide a full explanation of the details of each and every matter on the attached Professional Liability Information Addendum. The explanation must include the name of the court in which the suit was filed, the caption and docket number of the case, and the name and address of the attorney defending you, and all other relevant details. Include suits in which a judgment or settlement was made against a professional corporation of which you are/were a member, shareholder, or employee in any matter in which you were involved in the patient’s care.

A.	Has your professional liability insurance coverage ever been terminated by	No	Yes
	action of the insurance company?	No	Yes
	action of the insurance company?

B. Have you ever been denied professional liability insurance coverage?		No	Yes

C. Has any (current or previous) professional liability insurance carrier excluded
	any specific procedures or specific area of practice (e.g., obstetrics, surgery,	No	Yes
	etc.) from your coverage?

D. During the time of your professional practice, have you had any professional
	liability claims, suits, settlements, or judgments filed against you or are any	No	Yes
	currently pending?

E.	Have any restrictions ever been placed on your professional liability insurance	No	Yes
	coverage?	No	Yes
	coverage?

F. Have you ever practiced without professional liability coverage?		No	Yes

G. Are there any incidents for which you have been contacted by an attorney
	regarding potential professional liability (e.g., settlement requests, writ of	No	Yes
	summons, etc.)?

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Professional Liability Information Addendum

(Photocopy this form for each case/action)

Please supply the following and sign and date this form:

Information for each professional liability action you have had taken against you, including those pending.

Information for each settlement, or decision for the plaintiff that has ever occurred on your behalf.

Practitioner Signature and Date

All information is held in strict confidence and used for credentialing and recredentialing purposes only. Failure to supply sufficient details may prevent your application from being approved. In addition to completion of this form, practitioner may also submit any additional supporting documentation.

Check here if entire section is not applicable to applicant (and sign below even if no suits or settlements). Check here if no professional liability actions/claims filed (and sign below even if no suits or settlements).

1.	Case Number	2.	Carrier Name


3.	Name of Plaintiff	4.	Date of Incident


5.	Date Filed	6.	Date Closed


7.	What was/is your status in the case?	8.	What is the status of the case?

			Found for Defendant
	Primary Defendant		Dropped
			Dismissed Without Payment
	Co-Defendant		Pending
			Found for Plaintiff
	Other, please explain:		Settled Out of Court
			Under Appeal

9.	Amount of Any Settlement or Award?	10.	Date of any Settlement or Award

Please explain the following in detail. (If an item does not apply please check “N/A”)

11.What was the alleged harm to the patient?

12.What were you alleged to have done incorrectly or failed to do?

13.Describe the patient’s illness and related effects of the alleged harm.

14.Describe any other details you believe are pertinent to the case.

N/A

15.Identify any other parties named in the suit.

N/A

Practitioner Signature (REQUIRED)

Date (REQUIRED)

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16.Practice Disclosure Information

If the answer to any question below is yes, please provide a full explanation of the details on a separate sheet and attach.

A. Have any investigations been initiated or are any pending against you by any state	No	Yes
licensure board, registration board, or regulatory agency?	No	Yes
licensure board, registration board, or regulatory agency?

B. Has your license to practice in any state ever been voluntarily or involuntarily
relinquished, restricted, denied, reduced, limited, suspended, placed on probation,	No	Yes
revoked, or subject to any disciplinary action including reprimand?

C. Have you ever been suspended, sanctioned, or otherwise restricted from participating
or been the subject of an investigation in any private, federal, or state health insurance	No	Yes
program (e.g., Medicare, Medicaid)?

D. Has your narcotics (DEA) registration certificate (federal or state) ever been voluntarily
or involuntarily relinquished, limited, suspended, not renewed, placed on probation,	No	Yes	NA
revoked, or challenged?

E. Have you ever been convicted of or plead no contest to any criminal (felony or
misdemeanor) charges including a drug or alcohol-related offense or motor vehicle	No	Yes
offenses, but not including minor traffic or parking violations? Are any such	No	Yes

proceedings currently pending?

F. Have you ever had an academic appointment denied, limited, revoked, suspended,	No	Yes	NA
reduced, placed on probation, not renewed, or other adverse action taken?	No	Yes	NA


G. Have you ever been refused membership on the medical or allied health staff of any	No	Yes	NA
hospital or institution or been denied advancement in staff status?	No	Yes	NA


H. Has your employment, medical staff status, appointment, reappointment, or clinical
privileges, or scope of practice ever been voluntarily or involuntarily suspended,
restricted, reduced, revoked, denied, relinquished, not been renewed or subjected to	No	Yes
probationary conditions or limited at any hospital, managed care organization or other
health care entity?

I. Have you ever been denied membership or renewal, or been reprimanded, censured,
suspended, revoked, placed on probation, or otherwise sanctioned by any health care
organization, including but not limited to, hospitals, HMOs, PPOs, IPAs, PHOs,	No	Yes
professional associations or societies, professional standards review organization or	No	Yes

peer review organizations, or any other health care facilities, based on professional
competence?

J. Have your ever withdrawn your application for appointment, reappointment or request
for clinical privileges or resigned from the medical or allied health staff of a hospital,
managed care organization, or other health care entity while under investigation or	No	Yes
before a decision about your appointment or reappointment or clinical privileges was	No	Yes

rendered by the governing board of any hospital, managed care organization or any
other health care entity?

K. Have you ever been allowed to resign your position or voluntarily relinquish specific
clinical privileges rather than face any charge or investigation on the part of the	No	Yes
medical staff of a hospital, managed care organization, or other health care entity?

L. Are there currently pending adverse actions on your employment, medical staff
appointment, reappointment, clinical privileges or scope of practice at any hospital,	No	Yes
managed care organization, or other health care entity?

M. Has any investigation (other than normal performance improvement reviews) involving
your clinical practice, competence or professional conduct ever been initiated by any	No	Yes
hospital, managed care organization, governmental agency, other health care entity, or	No	Yes

branch of the armed forces?

N. Has your request for any specific clinical privileges or scope of practice ever been
denied (as a result of disciplinary action) or granted with stated limitations or	No	Yes
conditions (aside from ordinary initial probationary requirements of proctorship)? Are	No	Yes

such proceedings currently pending?

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Page 18

O. Do you have any knowledge of any civil actions pending against you by any hospital,	No	Yes
law enforcement agency, professional group or society?	No	Yes
law enforcement agency, professional group or society?

P. Have you had any charges of unprofessional conduct brought against you?	No	Yes

Q. Have you had any charges of fraud brought against you?	No	Yes

R. Have you received any confirmed Quality Citations from a Peer Review Organization
(PRO) in the last two (2) years? If you answered yes, on a separate sheet, indicate the	No	Yes
address of the PRO that cited you, the circumstances of the citation and the number of	No	Yes

points you were fined.

Health Status

Note: Your application will be processed in the usual manner regardless of how you answer questions A and B. If you have answered “No” to question A or B, please explain completely on a separate sheet. If you are found to be qualified, a representative will contact you to determine what accommodations are necessary and feasible to allow you to practice safely.

A. Are you physically and mentally able to perform all the essential functions or services
necessary to exercise the privileges or services applied for with or without a	Yes	No
reasonable accommodation?

B. Are you able to perform these functions without significant risk of injury to yourself or	Yes	No
others?	Yes	No
others?

C. Do you illegally use drugs?	Yes	No
Have you used illegal drugs within the last two years?	Yes	No

D. Do you currently take any medications that may affect your ability to perform the	Yes	No
clinical privileges or scope of practice requested competently and safely?	Yes	No

12/02; 3/03; 11/03; 1/04; 5/04; 10/04 **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq**

Page 19

Health Care Entity:

WEST VIRGINIA PRACTITIONER

ATTESTATION/AUTHORIZATION AND RELEASE OF INFORMATION

By submitting this attestation/authorization and release of information form in conjunction with the West Virginia Credentialing Form (WVCF) and/or the West Virginia Practitioner Attestation/Authorization, I understand and agree as follows:

1.I understand and acknowledge that, as an applicant for medical staff membership and/or participating status with the Health Care Entity indicated on the WVCF for initial credentialing or recredentialing, I have the burden of producing adequate information for proper evaluation of my competence, character, ethics, mental and physical health status, and/or other qualifications.

2.I further understand and acknowledge that the Health Care Entity or designated Agent 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 Health Care Entity as part of the verification and credentialing process.

3.I authorize all individuals, institutions, and entities or organizations with which I am currently or have been associated and all professional liability insurers with which I have had or currently have professional liability insurance, who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information to the designated Health Care Entity(ies), their staffs and agents.

4.I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry out the requested clinical privileges or provide services I request. I authorize each and every individual and organization in custody of such records and documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested.

5.I attest to the accuracy and completeness of the information provided. I understand and agree that any misstatements in or omissions from the WVCF Attestation/Authorization and attachments hereto may constitute cause for denial of the application or summary dismissal or termination of membership/clinical privileges/participation agreement.

6.I agree to exhaust all available procedures and remedies as outlined by in the bylaws, rules, regulations, and policies, and/or contractual agreements of the Health Care Entity(ies) where I have membership and/or clinical privileges/participation.

7.I understand that completion and submission of the WVCF Attestation/Authorization and Release of Information does not automatically grant me membership or clinical privileges/participating status with the Health Care Entity(ies) indicated on the WVCF or Attestation/Authorization.

8.I further acknowledge that I have read and understand the foregoing Attestation/Authorization and Release of Information. A photocopy of this Attestation/Authorization and Release of Information shall be as effective as the original, and authorization constitutes my written authorization and request to communicate any relevant information and to release any and all supportive documentation regarding this application/attestation/authorization.

9.I release from liability any and all individuals and organizations who provide information to the credentialing entity in good faith and without malice concerning my professional qualifications and competence, and the credentialing entity, from liability for their acts performed and

statements made relating but not limited to verifying, evaluating and acting upon my credentials and qualifications.

Print Name Here:

Signature:

Date: _________________________

NOTE: Through above signature, I hereby affirm that contents are current, accurate, and complete as of the signature date. Modification to the wording or format of the WVCF/Attestation/Authorization and Release of Information may invalidate an application.

Credentialing Entity may supplement additional Attestation/Authorization/Release of Information through an additional release document as required by the entity.

The Entities will treat this application and any information secured in connection therewith in strict confidence in accordance with the Entities’ policies and/or Medical Staff Bylaws and preserve with all reasonable safeguards the privacy of the Applicant.

12/02; 3/03; 11/03; 1/04; 5/04; 10/04 **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq**

Page 20

ADDENDUM

VERIFICATION OF PROFESSIONAL LIABILITY

I, the undersigned, authorize my CURRENT professional liability insurance carrier,

(Enter Current Professional Liability Insurance Carrier Name)

(Enter Street Address)(City)(State & Zip)

to send verification of my professional liability coverage, to include dates of coverage, amounts of coverage, and any limitations in


coverage, to			.
	(Entity Specific)
		is to hereinafter be

	(Entity Specific)

a Certificate Holder and is to be notified of the amount of my coverage and any future changes in my insurance status, to include all information regarding claims history (but not necessarily limited to judgments entered, claims settled, cases and lawsuits pending), and any restriction regarding specific privileges which may be excluded from coverage.

I will notify			of any
	(Entity Specific)
changes in Professional Liability carriers so that another Verification of Professional Liability form can be completed.
____________________________________________________		____________________________________
Practitioner’s Signature		Date

Printed Name

Policy Number

(Instructions: Please complete, sign, date and return to entity named above with your initial application.)

12/02; 3/03; 11/03; 1/04; 5/04; 10/04 **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq**

Page 21

Question	Answer
Form Name	Wv Credentialing Form
Form Length	21 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 15 sec
Other names	state of wv credentialing application, state of wv credentialing form, caqh credentialing form, west virginia credentialing

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