CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS

Size: px
Start display at page:

Download "CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS"

Transcription

1 CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS

2 August 29, 2017 Dear Applicant, We appreciate your interest in becoming a part of Valleygate Dental Surgery Centers. Prior to beginning your service with Valleygate you must complete our credentialing process and be approved by our credentialing committee. Our credentialing policy is compliant with AAAHC standards. Our Privileging applies to Dentists, Physicians and CRNA s (licensed independent healthcare practitioners) who wish to provide services in any of our Valleygate Dental Surgery Centers. All interested clinicians will receive a Pre-Application and qualified applicants will receive a full application for clinical privileges. We have streamlined our process and will make every effort to process your application in a timely and efficient manner. The credentialing process consists of six-steps, which are as follows: Step 1: Applicant will submit a pre-application Step 2: Applicant will receive the applicant packet. Step 3: Applicant will return completed applications along with requested documents. Step 4: Application will be reviewed and processed by our Credentialing Specialist to make sure all information is complete and accurate and verified with the appropriate third parties. Step 5: The completed applicant packet will be forwarded to the Dental Director and reviewed by the Credentialing Committee. Their recommendation will be forwarded to the Chief Operating Officer for final approval. Step 6. Applicant will be notified of result. Although we will do everything to ensure there are no delays, the credentialing process may take up to 60 days to verify, review, and obtain final approval. To expedite the process, your application should be without blanks or missing requested documents; if anything is missing, the process will be delayed. If at any time, you have questions please contact the Dental Director or Compliance Officer at Valleygate so we may resolve any problems prior to submission. Our goal is to assist you while ensuring that we are compliant with the Accreditation Association for Ambulatory Health Care (AAAHC) and other relevant guidelines. Sincerely, Erica Kennerson Compliance Officer Valleygate Dental Surgery Centers Dr F McGibbon Dental Director Valleygate Dental Surgery Center of Fayetteville Dr A Dodds Dental Director Valleygate Dental Surgery Center of Greensboro ekennerson@vfdental.com FMcGibbon@vfdental.com doddsap@earthlink.net

3 Pre-Application The applicant must state his/her intention for application. The pre-application will be forwarded to the Dental Director and the Chief Operating Officer. If approved, the full application privilege forms will be mailed to the applicant. If the Applicant s pre-application does not meet the requirements for becoming an LIP of the Facility or indicates that the Facility is unable to accommodate the Applicant, then the Applicant shall be informed of this in writing within fourteen (14) days from the date the pre-application is stamped received. Fayetteville Greensboro Charlotte I A. PERSONAL INFORMATION 2. Name (Last, First, Middle) Degree/Professional Title Gender: Male Female Other Names You May Have Used (Maiden, a.k.a., etc.) Home Address/Street City/State/Zip Home Telephone No. Home Fax No. Address Date of Birth (Month/Day/Year) Citizenship/Place of Birth Languages fluently spoken (in addition to English) Languages written in addition to English Social Security No. Ethnicity (Optional) 16. If you are not a US Citizen do you have authorization to work in the US? 17. NPI number Medicare number Medicaid number I B. PRACTICE SPECIALTY FOR WHICH YOU ARE SEEKING AFFILIATION Are you applying as a: Pediatric Dentist Oral Surgeon General dentist Anesthesiologist CRNA Other II. PROFESSIONAL SCHOOL List all Dental/ Medical/Professional Schools/Institutions attended including undergraduate and graduate school for CRNA s. Enclose copies of your diplomas and certificates. Dental /Medical/Professional School Degree Awarded Date of Graduation (mm/yy) 2. Dental /Professional School Degree Awarded Date of Graduation (mm/yy)

4 III. POST GRADUATE TRAINING INTERNSHIP Program successfully completed? 2. RESIDENCY Program successfully completed? 3. FELLOWSHIP Program successfully completed? IV. HOSPITAL / FACILITY HISTORY CURRENT Primary Admitting Facility Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Department/Specialty Staff Category Chairperson Telephone No. V. WORK HISTORY Current Practice Contact Name Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Telephone No. If at current practice/hospital for less than three years please include information regarding previous employer 2. Previous Practice Contact Name Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Telephone No.

5 VI. OTHER DISCLOSURES Please answer all of the following: Has your license to practice dentistry/medicine in any jurisdiction ever been voluntarily or involuntarily suspended, limited, revoked, or sanctioned in any way? 2. Have you ever been denied a license to practice dentistry/medicine? 4. Have you ever had a request for a specific clinical privilege denied? 5. Have you ever been suspended, voluntarily or involuntarily sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program? 7. Has your federal narcotics registration (DEA) ever been voluntarily or involuntarily suspended or revoked? 9. Have you ever been the subject of any disciplinary proceedings at any healthcare facility, to include behavior deemed inappropriate? 10. Have you ever been convicted of or pled guilty to or entered into a plea agreement for a violation of any law or ordinance other than traffic offenses, but including driving while under the influence of alcohol or any other substance? 1 Have you ever been denied professional liability insurance? 13. Have any professional liability suits ever been filed against you? 14. Have any professional liability suits filed against you resulted in judgment against you or been terminated pursuant to a settlement in which you have paid damages to the plaintiff with or without admitting liability? 15. Have you ever settled any professional liability claim against you prior to suit and admitted liability as a part of such settlement? 16. Has any claim of sexual harassment or violation of civil rights ever been made against you that resulted in your receiving or incurring any warning, disciplinary action, or civil liability? 17. Have you ever enrolled or are you currently enrolled in a structured assistance program designed to help deal with substance abuse or behavior problems? Applicant s Signature: Print Name: Date: Return Form by Mail to: Valleygate Dental Surgery Centers ATTN: Erica Kennerson 2015 Valleygate Drive Fayetteville, NC to: ekennerson@vfdental.com In-person to: 2015 Valleygate Drive, Fayetteville, NC (In sealed envelope with ATTN: Erica Kennerson)

VNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION

VNSNY CHOICE PRACTITIONER CREDENTIALING APPLICATION Attached please find an application for participation with VNSNY CHOICE. Upon completion, please forward this application to: VNSNY CHOICE Attn: Provider Relations Network Development 1250 Broadway - 11th

More information

SC Uniform Managed Care Provider Credentialing Application

SC Uniform Managed Care Provider Credentialing Application SC Uniform Managed Care Provider Credentialing Application I. PERSONAL INFORMATION Solo Practice Group Practice Name: Last First M.I. Suffix Degree Maiden and/or other name List W-9 name if different Place

More information

CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process.

CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process. CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process. PERSONAL IDENTIFICATION DATA Last Name: First: MI: Degree: Date of Birth: Social Security

More information

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( ) (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

Standardized. Credentialing Form To Be Used By Health Maintenance Organizations Licensed in the State of Missouri

Standardized. Credentialing Form To Be Used By Health Maintenance Organizations Licensed in the State of Missouri I. GENERAL INFORMATION Standardized Credentialing Form To Be Used By Health Maintenance Organizations Licensed in the State of Missouri COMPLETE EACH SECTION AS THOROUGHLY AS POSSIBLE. PLEASE TYPE OR PRINT

More information

Idaho Practitioner Application

Idaho Practitioner Application Idaho Practitioner Application To use the Idaho Practitioner Application (IPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When a request

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

PRACTICE INFORMATION AND LETTER AGREEMENT FORM. COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747

PRACTICE INFORMATION AND LETTER AGREEMENT FORM. COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747 PRACTICE INFORMATION AND LETTER AGREEMENT FORM COMPLETE, SIGN AND RETURN TO: One Huntington Quadrangle Suite 1N09 Melville, NY 11747 PERSONAL DATA Last Name First Name License Number Tax I.D. Number for

More information

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan

To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 1. Complete the SC Uniform Managed Care Provider Credentialing Application. 2. Enclose copies of the following items: A. State

More information

MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD.

MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD. MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD. APPLICANT NAME: SPECIALTY: In order to expedite the credentialing process, please complete every item

More information

This letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana.

This letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana. ATTN: AmeriHealth Caritas Louisiana Providers RE: Provider Re-Credentialing CAQH ID: Dear Credentialing Contact: This letter is to let you know that you are due for re-credentialing as a participating

More information

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application)

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) Prior to completing this credentialing application, please read and observe the following: Healthcare Organizations may contract

More information

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT

More information

Molina Healthcare of Wisconsin, Inc. Practitioner Application

Molina Healthcare of Wisconsin, Inc. Practitioner Application Molina Healthcare of Wisconsin, Inc. Practitioner Application 1. INSTRUCTIONS This form should be: Typed or legibly printed in black or blue ink. Keep a copy of the application on file for future requests.

More information

Network Participant Credentialing Application

Network Participant Credentialing Application Please: Type or print legibly Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Include the following with your application, if applicable: Copy of professional license(s)

More information

ALLIED HEALTH STAFF CREDENTIALING APPLICATION

ALLIED HEALTH STAFF CREDENTIALING APPLICATION ALLIED HEALTH STAFF CREDENTIALING APPLICATION This application may be used at the hospitals listed below. The Medical Staff office phone numbers of the participating hospitals are as follows: Phone Hospital

More information

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax) Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \

More information

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE: *Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE

More information

CRNA INITIAL CREDENTIALING APPLICATION

CRNA INITIAL CREDENTIALING APPLICATION CRNA INITIAL CREDENTIALING APPLICATION Revised 01/12 GENERAL INSTRUCTIONS LocumTenens.com CVO must credential all providers prior to placement into any practice location. All information requested in this

More information

APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE

APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE APPLICATION FOR REAPPOINTMENT RESEARCH ASSOCIATE Enclosed is an application for reappointment to the position of Research Associate. We ask that you review the shaded areas to assure that all current information

More information

Legal Last Name First Middle Professional Title/Degree

Legal Last Name First Middle Professional Title/Degree IOWA STATEWIDE UNIVERSAL PRACTITIONER RECREDENTIALING APPLICATION Type or print responses in ink. A CV or See CV may not be use in lieu of completing any answers on this application. Review or complete

More information

ALLIED HEALTH PROFESSIONAL CREDENTIALING APPLICATION FORM

ALLIED HEALTH PROFESSIONAL CREDENTIALING APPLICATION FORM ALLIED HEALTH PROFESSIONAL CREDENTIALING APPLICATION FORM Independent Practitioners: Acupuncturist, Audiologist, Dietitian, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Licensed

More information

Please Note: Please send all documentation related to the credentialing portion of this documentation to:

Please Note: Please send all documentation related to the credentialing portion of this documentation to: Please ote: The application process is split into different actions. Please send all documentation related to the contracting portion of this documentation to: Fax to: (916)350-8860 Or email to: BSCproviderinfo@blueshieldca.com

More information

NASI Per Diem Malpractice

NASI Per Diem Malpractice Dear Nurse Anesthetist, We appreciate your interest in NASI s Per Diem Malpractice Insurance. This service is for those providers who need a supplemental policy for working an assignment outside of their

More information

Research Associate Application Dear Practitioner:

Research Associate Application Dear Practitioner: KALEIDA HEALTH Research Associate Application Dear Practitioner: Enclosed is an application for status as a Research Associate and the appropriate job description. Please return the completed application

More information

BCBS NC Blue Medicare Credentialing Instructions

BCBS NC Blue Medicare Credentialing Instructions BCBS C Blue Medicare Credentialing Instructions Licensed Certified Social Worker (LCSW) Certified Substance Abuse Counselor (CSAC) Licensed Clinical Addiction Specialist (LCAS) Licensed Marriage and Family

More information

I. PERSONAL INFORMATION. Degree and/or Title SS# . Non-physician Practitioner (Please specify )

I. PERSONAL INFORMATION. Degree and/or Title SS#  . Non-physician Practitioner (Please specify ) Pennsylvania Standard Application This form should be typed or legibly printed in black or blue ink. Please answer all questions completely and fully. If more space is needed than provided on this application,

More information

SECTION ONE - PERSONAL INFORMATION SECTION TWO - EDUCATION INFORMATION

SECTION ONE - PERSONAL INFORMATION SECTION TWO - EDUCATION INFORMATION Attachment H ALLIED HEALTH PROFESSIONALS INITIAL APPOINTMENT ADDENDUM TO THE TEXAS DEPARTMENT OF INSURANCE (TDI) STANDARDIZED CREDENTIALING APPLICATION SECTION ONE - PERSONAL INFORMATION Last Name: First

More information

Massachusetts Integrated Application for Re-Credentialing/Re-Appointment

Massachusetts Integrated Application for Re-Credentialing/Re-Appointment Massachusetts Integrated Application for Re-Credentialing/Re-Appointment Name (Please type or print) Degrees MA License. Are you currently in the United States on a temporary visa? ** **Identify type of

More information

Practitioner Credentialing Criteria for Participation and Termination

Practitioner Credentialing Criteria for Participation and Termination Practitioner Credentialing Criteria for Participation and Termination I. Statement of Purpose Regence (referred to hereinafter as the Company ) is firmly committed to the development of networks with practitioners

More information

Ohio Department of Insurance

Ohio Department of Insurance Ohio Department of Insurance STANDARDIZED CREDENTIALING FORM Please complete each section thoroughly. Attach additional sheets where necessary. Type or print clearly in black ink. Sign and date the application.

More information

GENERAL INFORMATION. English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other

GENERAL INFORMATION. English Spanish Arabic Chinese French German Hmong Hindi Laotian Philippine Vietnamese Other **INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS** 1. Please print or type ALL responses. 2. If you need additional space to complete a section, please attach additional sheets. 3. If you

More information

Credentialing Application

Credentialing Application Credentialing Application If you are active with CAQH it is not necessary for you to complete the application in this packet. In order for Meridian Health Plan to process your contract the following information

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): Florida Certified Nursing Assistant Examination Application *APPCNAFL* Instructions: Please go to www.prometric.com/nurseaide/fl to print the current version of this application and all other forms. DO

More information

APPLICATION FOR APPOINTMENT Northeast Florida Healthcare Organization Revision Date: 9/2016

APPLICATION FOR APPOINTMENT Northeast Florida Healthcare Organization Revision Date: 9/2016 APPLICATION FOR APPOINTMENT rtheast Florida Healthcare Organization Revision Date: 9/2016 Personal NAME: (LN, FN, MN) AKA or Maiden Name(s) Professional Degree: DMD DOB: SS#: Medicaid #: NPI #: SS# used

More information

Eye Medical Provider Practice Application

Eye Medical Provider Practice Application and subsidiaries Eye Medical Provider Practice Application How to Join the Avesis Network. Complete and sign the application Complete and sign the W-9 Complete and sign the Credential Verification Release

More information

Credentialing Application

Credentialing Application Credentialing Application 1. NAME Last First MI Degree Gender 2. BIRTH, SOCIAL SECURITY & E-MAIL ADDRESS Date of Birth Social Security # E-Mail Address 3. PRACTICE, OFFICE & SPECIALTY INFORMATION 3.1 Please

More information

TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM

TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM Application Instructions: Complete the application in full. The application must be typed or neatly printed. Attach additional sheets

More information

Credentialing Application Packet. Dear Resident Applicant,

Credentialing Application Packet. Dear Resident Applicant, Credentialing Application Packet Salina Family Healthcare Center A Federally Qualified Community Health Center 651 E. Prescott, Salina, KS 67401 Medical Center ~ (785) 825-7251 Dental Center ~ (785) 826-9017

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): Florida Certified Nursing Assistant Examination Application *APPCNAFL* Instructions: Please go to www.prometric.com/nurseaide/fl to print the current version of this application and all other forms. DO

More information

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must be completed in its entirety 3. Must be signed and dated 4.

More information

This document describes the internal Harbor Health Plan's criteria for credentialing and recredentialing.

This document describes the internal Harbor Health Plan's criteria for credentialing and recredentialing. vc I. SCOPE: This document describes the internal 's criteria for credentialing and recredentialing. II. POLICY: 's criteria for credentialing and recredentialing will be compliant with legal and accreditation

More information

Graduate Medical Education. Division of Cardiology Phone: Fax:

Graduate Medical Education. Division of Cardiology Phone: Fax: Office of Graduate Medical Education Division of Cardiology Phone: 662-293-7687 Fax: 662-293-4347 Dear Doctor: Attached is an application for our Cardiology fellowship program. Please submit all information

More information

YALE-NEW HAVEN HOSPITAL MEDICAL STAFF POLICY & PROCEDURE CONFLICT OF INTEREST

YALE-NEW HAVEN HOSPITAL MEDICAL STAFF POLICY & PROCEDURE CONFLICT OF INTEREST YALE-NEW HAVEN HOSPITAL MEDICAL STAFF POLICY & PROCEDURE CONFLICT OF INTEREST Definitions External financial interests can create conflicts when they provide an incentive to a Medical Staff member to affect

More information

***CAPS will not begin processing your application until ALL of the above items (numbers 1-4) are returned***

***CAPS will not begin processing your application until ALL of the above items (numbers 1-4) are returned*** As a service to providers and the community, the Greater Louisville Medical Society (GLMS) offers a Centralized Application Processing Service (CAPS). The GLMS CAPS department verifies: education, training,

More information

Department: Legal Department. Approved by:

Department: Legal Department. Approved by: HAWAII HEALTH SYSTEMS C O R P O R A T I O N Touching Lives Everyday" Policies and Procedures Subject: Credentialing Requirements Department: Legal Department Issued by: Rene McWade, Esq. VP & General Counsel

More information

Facility and Ancillary Credentialing Application INSTRUCTIONS

Facility and Ancillary Credentialing Application INSTRUCTIONS Facility and Ancillary Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided as

More information

REINSTATEMENT APPLICATION PACKET:

REINSTATEMENT APPLICATION PACKET: REINSTATEMENT APPLICATION PACKET: According to the SC Code of Laws, Chapter 63, Section 40-63-250(E), expired licenses can be reinstated only with successful completion of a Reinstatement Application Packet

More information

PROVIDER CREDENTIALING APPLICATION

PROVIDER CREDENTIALING APPLICATION PROVIDER CREDENTIALING APPLICATION We appreciate your interest in becoming a TRICARE network provider, offering medical services for Prime Beneficiaries. STEP 1. Contact your Provider Education and Relations

More information

MEDICAID ENROLLMENT PACKET

MEDICAID ENROLLMENT PACKET MEDICAID ENROLLMENT PACKET Follow the steps below. This will prevent errors which will delay enrollment. Physicians Only: 1. Answer the one page questionnaire 2. SIGN EACH FORM where it indicates Signature

More information

Please accurately complete the entire application. No action will be taken on applications with missing information.

Please accurately complete the entire application. No action will be taken on applications with missing information. 2508 E. Fox Farm Road, 1-1A Cheyenne, WY 82007 (307) 635-3618 Fax: (307) 635-1442 www.wyhealthworks.org Application for Employment (HealthWorks does not discriminate based on color, creed, religion, national

More information

Idaho Practitioner Credentials Verification Checklist

Idaho Practitioner Credentials Verification Checklist Idaho Practitioner Credentials Verification Checklist The following documentation is required when submitting a practitioner credentialing application. Please complete the information below and return

More information

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-CHILD (QMHP-C)

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-CHILD (QMHP-C) REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-CHILD (QMHP-C) Qualified Mental Health Professional-Child or QMHP-C means a registered QMHP who is trained and experienced in providing

More information

Provider Selection Criteria for PreferredOne Participating Dentists/Oral Surgeons

Provider Selection Criteria for PreferredOne Participating Dentists/Oral Surgeons Provider Selection Criteria for PreferredOne Participating Dentists/Oral Surgeons General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

DEVELOPMENTAL DISABILITIES INDIVIDUAL LETTER OF INTENT

DEVELOPMENTAL DISABILITIES INDIVIDUAL LETTER OF INTENT DEVELOPMENTAL DISABILITIES INDIVIDUAL LETTER OF INTENT To ensure timely processing of your application, please return the following checklist completed Letter of Intent (LOI) and documents requested to:

More information

Oncology Nurse Practitioner Fellowship Application

Oncology Nurse Practitioner Fellowship Application Oncology Nurse Practitioner Fellowship Application I. General Information Use this form to apply for full time appointment to the Nurse Practitioner Fellowship in Oncology at Sylvester Comprehensive Cancer

More information

APPLICATION CHECKLIST IMPORTANT

APPLICATION CHECKLIST IMPORTANT State of Florida Department of Business and Professional Regulation Division of Professions: Talent Agencies Application for Change of Owner or Operator Form # DBPR TA-2 APPLICATION CHECKLIST IMPORTANT

More information

Behavioral Health Facility and Ancillary Credentialing Application

Behavioral Health Facility and Ancillary Credentialing Application Behavioral Health Facility and Ancillary Credentialing Application Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided

More information

Utah medical & controlled substance license instructions Division of Occupational and Physician Licensing (DOPL) rev: 8/9/16

Utah medical & controlled substance license instructions Division of Occupational and Physician Licensing (DOPL) rev: 8/9/16 Utah medical & controlled substance license instructions Division of Occupational and Physician Licensing (DOPL) rev: 8/9/16 Programs Exempt from the Utah controlled substance license: ALL Pathology and

More information

ENROLLMENT APPLICATION

ENROLLMENT APPLICATION Alabama Medicaid ENROLLMENT APPLICATION LIMITED ENROLLMENT AS A NON-MEDICAID PROVIDER FOR ORDERING, PRESCRIBING OR REFERRING (OPR) PHYSICIANS AND NON-PHYSICIAN PRACTITIONERS In accordance with the implementation

More information

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A)

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A) REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A) Qualified Mental Health Professional-Adult or QMHP-A means a registered QMHP who is trained and experienced in providing

More information

Practitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period.

Practitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period. SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN RECREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-02 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed by contract

More information

(907) PHONE (907) FAX

(907) PHONE (907) FAX 3260 Hospital Drive Juneau, AK 99801 Application for Medical, Nurse Practitioner, and Physician Assistant Students Bartlett Regional Hospital Medical Staff Services Office 3260 Hospital Drive Juneau, AK

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

Certified Registered Nurse Anesthetist (CRNA) Application. Full Name Nickname. Address. City State Zip County. Home Phone Cell Phone

Certified Registered Nurse Anesthetist (CRNA) Application. Full Name Nickname. Address. City State Zip County. Home Phone Cell Phone Certified Registered Nurse Anesthetist (CRNA) Application Date of Application: I. Personal Information: Full Name Nickname Address City State Zip County Home Phone Cell Phone Email Pager/Alt. Email Sex:

More information

The Plan will not credential trainees who do not maintain a separate and distinct practice from their training practice.

The Plan will not credential trainees who do not maintain a separate and distinct practice from their training practice. SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN INITIAL CREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-01 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed

More information

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. 1 of 11 State of Florida Department of Business and Professional Regulation Building Code Administrators and Inspectors Board Application for Authorization to Take the Principles and Practice Examination

More information

State Board of Health

State Board of Health DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Adopted by the State Board of Health 03/21/07, effective 10/30/11 State Board of Health 6 CCR 1014-4 COLORADO HEALTH CARE PROFESSIONAL CREDENTIALS APPLICATION

More information

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must

More information

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION Name: NAME - Last: First: Middle: Title/Degree:! Type or print responses in ink.! Complete this form in its entirety and attach all requested

More information

APPLICATION FOR NATUROPATHIC DOCTOR

APPLICATION FOR NATUROPATHIC DOCTOR APPLICATION FOR NATUROPATHIC DOCTOR Completion of this application form is necessary for consideration for licensure. Disclosure of this information is voluntary; however, failure to disclose all requested

More information

Iowa Medicaid Universal Provider Enrollment Application. Basic Information

Iowa Medicaid Universal Provider Enrollment Application. Basic Information Iowa Department of Human Services Iowa Medicaid Universal Provider Enrollment Application Basic Information To avoid delays in the enrollment process, you should: Complete all required forms listed below.

More information

Provider Credentialing

Provider Credentialing I. Purpose The purpose of this Policy and Procedure is to establish the process including written guidelines and standards for the credentialing and re-credentialing of all clinicians defined in this policy.

More information

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION Name: IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION NAME: Last Name First Name Middle Name Title Type or print responses in ink. Complete this form in its entirety and attach all requested

More information

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION

IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION IOWA STATEWIDE UNIVERSAL PRACTITIONER CREDENTIALING APPLICATION NAME: Last Name First Name Middle Name Title Type or print responses in ink. Complete this form in its entirety and attach all requested

More information

ASSOCIATE MEMBERSHIP ORTHOPAEDIC

ASSOCIATE MEMBERSHIP ORTHOPAEDIC We invite you to Apply for ASSOCIATE MEMBERSHIP ORTHOPAEDIC Application and Instruction Booklet Class of 2018 FINAL Application Deadline: April 1, 2017 ** All documents must be in the AAOS office by this

More information

Curriculum Vitae (must be in month/year format)

Curriculum Vitae (must be in month/year format) TRIWEST PROVIDER NETWORK DEVELOPMENT PRACTITIONER RE-CREDENTIALING CHECKLIST To expedite processing of your application in the UNMH VAPC3/Choice Network, please complete this application in its entirety

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions.

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions. ATTENTION! Criminal History Record Checks (CHRC) are required for all applicants. The Board may not reinstate or issue a new license to any applicant, physician or allied health practitioner, if the Board

More information

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft 5-15-13 DEFINITIONS ADVANCED PROFESSIONAL PRACTITIONER (APP): Advanced Practice Nurses, including advanced

More information

PRACTITIONER CREDENTIALING APPLICATION

PRACTITIONER CREDENTIALING APPLICATION PRACTITIOER CREDETIALIG APPLICATIO otice to applicants: Encore conducts continuous open enrollment for new practitioners who meet minimum criteria. Minimum criteria for consideration by Encore Credentialing

More information

Text Facsimile of Online Physician Licensure Application

Text Facsimile of Online Physician Licensure Application Text Facsimile of Online Physician Licensure Application Login Physician Licensure Application Information you enter will automatically saved at the end of every page. You must complete the application

More information

Thank you for your interest in applying to the Traditional BSN Entry Option at NC Agricultural & Technical State University School of Nursing.

Thank you for your interest in applying to the Traditional BSN Entry Option at NC Agricultural & Technical State University School of Nursing. Dear Applicant: North Carolina Agricultural and Technical State University Thank you for your interest in applying to the Traditional BSN Entry Option at NC Agricultural & Technical State University School

More information

Mental Health Consultants Inc. (MHC) Provider Application

Mental Health Consultants Inc. (MHC) Provider Application Mental Health Consultants Inc. (MHC) Provider Application To apply online, please visit our website at www.mhconsultants.com. Complete and Return to MHC: Mail: 1501 Lower State Road, Building D, Suite

More information

Present Address Telephone ( ) Street City State Zip. Permanent Address Telephone ( ) Social Security Number / / address

Present Address Telephone ( ) Street City State Zip. Permanent Address Telephone ( ) Social Security Number / /  address Application for Classified Personnel Minden Public Schools An Equal Opportunity/Affirmative Action Employer 543 West Third Phone: (308) 832-2440 Minden, NE 68959 Fax: (308) 832-2567 Please type or print

More information

Organizational Provider Credentialing Application

Organizational Provider Credentialing Application Prior to completing this credentialing application, please read and observe the following: INSTRUCTIONS This form should be typed (using a different font than the form) or legibly printed in black or blue

More information

Rutherford Co. Rescue

Rutherford Co. Rescue RCLAFA, INC. Rutherford Co. Rescue Application You are only allowed to check one that you are applying for: Reserve Status Specialty Rescue Team Part-Time Paid Employee This application must be completely

More information

WASHINGTON STATE CONTINUING EDUCATIONAL STAFF ASSOCIATE CERTIFICATION REQUIREMENTS

WASHINGTON STATE CONTINUING EDUCATIONAL STAFF ASSOCIATE CERTIFICATION REQUIREMENTS WASHINGTON STATE CONTINUING EDUCATIONAL STAFF ASSOCIATE CERTIFICATION REQUIREMENTS School Nurse, School Occupational Therapist, School Physical Therapist, School Social Worker, School Speech Language Pathologist

More information

SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY

SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY Adopted by the Medical Staff: April 16, 2009 Approved by the Board: April 20, 2009 Revised by the

More information

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions.

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions. ATTENTION! Criminal History Record Checks (CHRC) are required for all applicants. The Board may not reinstate or issue a new license to any applicant, physician or allied health practitioner, if the Board

More information

A $ application fee in the form of a money order made payable to LSBN must accompany this form.

A $ application fee in the form of a money order made payable to LSBN must accompany this form. OFFICE USE ONLY: APPROVED BY (initial) DATE PERMIT ISSUED RN LICENSE NUMBER DATE RN LICENSE ISSUED ATTACH 2 X 2 PHOTO With tape only - Attach a 2 x 2 inch passport type, fade-proof photo taken in the last

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

Instructions and Application for Speech Language Pathologist

Instructions and Application for Speech Language Pathologist HEALTH OCCUPATIONS PROGRAM Speech Language Pathology and Audiology P.O. Box 64882, St. Paul, Minnesota 55164-0882 Telephone: (651) 201-3726 Fax: (651) 201-3839 Email: health.slpa@state.mn.us Instructions

More information

Values Accountability Integrity Service Excellence Innovation Collaboration

Values Accountability Integrity Service Excellence Innovation Collaboration n00256 Recredentialing Process Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The purpose of recredentialing is to assure that Network Health Plan/Network

More information

Instructions and Application for Speech Language Pathologist Method 3, Meet all requirements for certifications(s) but do not have certification

Instructions and Application for Speech Language Pathologist Method 3, Meet all requirements for certifications(s) but do not have certification HEALTH OCCUPATIONS PROGRAM Speech Language Pathology and Audiology P.O. Box 64882, St. Paul, Minnesota 55164-0882 Telephone: (651) 201-3726 Fax: (651) 201-3839 Email: health.slpa@state.mn.us Instructions

More information

What is your start date? (Date in which you plan to begin seeing patients in the hospital). Specialty SECTION I. IDENTIFICATION DATA

What is your start date? (Date in which you plan to begin seeing patients in the hospital). Specialty SECTION I. IDENTIFICATION DATA This Application is for Non-employed Clinical Assistants (RN, dental assistant, orthotist, etc) who wish to assist a supervising physician at one or more of our facilities. Advanced Practice Nurses (CRNA,

More information

Medicare Manual Update Section 2 Credentialing (pg 15-23) SECTION 2: CREDENTIALING. 2.1 : Credentialing Policies & Procedures

Medicare Manual Update Section 2 Credentialing (pg 15-23) SECTION 2: CREDENTIALING. 2.1 : Credentialing Policies & Procedures SECTION 2: CREDENTIALING The credentialing program applies to all direct-contracted and those who are affiliated with Care1st through their relationship with a contracted PPG (delegated IPA/MG). Care1st

More information

DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT. State Board of Health

DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT. State Board of Health DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Adopted by the State Board of Health 08/16/17, effective 12/15/17 State Board of Health 6 CCR 1014-4 COLORADO HEALTH CARE PROFESSIONAL CREDENTIALS APPLICATION

More information

Today s date: Social Security Number: Birth Date MM/DD/YY / / City State Zip Parish/County

Today s date: Social Security Number: Birth Date MM/DD/YY / / City State Zip Parish/County APPLICATION FOR ADMISSION GRADUATE PROGRAM MSN-FNP PROGRAM OFFICE OF ADMISSIONS 5414 Brittany Drive, Baton Rouge, Louisiana 70808 (225) 768-1700 I. IDENTIFYING INFORMATION: Today s date: Social Security

More information