Section 965.APPENDIX A Health Care Professional
Credentialing and Business Data Gathering Form
STATE OF ILLINOIS
Health Care
Professional Credentialing and Business Data Gathering Form
The Health Care Professional Credentials Data Collection Act
[410 ILCS 517] requires that this form be collected from health care professionals
by hospitals, health care entities, and health care plans that desire to
credential such professional. Each hospital, health care entity, and health care
plan may also require completion of supplemental forms.
INSTRUCTIONS
This form is for initial credentialing only. Other forms
are required for recredentialing and for updating information. YOU ONLY HAVE
TO FILL OUT AND SUBMIT WHAT IS REQUIRESTED BY THE CREDENTIALING ENTITY. PLEASE
REFER TO THE INSTRUCTIONS PROVIDED TO YOU BY THE ORGANIZATION YOU ARE APPLYING
TO FOR THEIR REQUIREMENTS.
This form has been segmented into 2 different Chapters, each
containing various sections:
Chapter A: General and Practice
Information
Chapter B: Business Information
As previously noted, please consult the specific
credentialing entity instructions for their individual Chapter or section
requirements for submission.
GENERAL INSTRUCTIONS: Wherever this application requests
information but does not provide sufficient space to provide a complete
response (for example, you have more licenses, specialties, work history, etc.)
provide attachments that contain all of the information requested in the
relevant section OR duplicate the relevant section as many times as necessary
and attach it to the back of this application.
The data marked as “Confidential Information” shall be
maintained in confidence to the extent required by law. They may be used by
the health care plan, entity or hospital and by their agents for credentialing
and internal business purposes. Other data contained in this form may be
released.
ATTACHMENTS
Attach Forms A-F as needed to support "yes"
responses in the Professional History section and copies of the following:
Curriculum Vitae
CONFIDENTIAL INFORMATION:
All Current Professional
Licenses
Current Federal DEA License,
If Applicable
Current State Controlled
Substances Licenses, If Applicable
Current Professional Liability Insurance Face Sheet or Declaration of Insurance with
Effective Date, Expiration Date and Amount Displayed Per Occurrence and In
Aggregate
Current CLIA Certificate, If
Applicable
Current W-9s, If Applicable
ECFMG Certificate, If
Applicable
Professional School Diploma, Residency Certificates, Fellowship Certificates, and
Board Certifications, As Applicable
AFFIRMATION OF
INFORMATION
I represent and warrant that all of the information provided
and the responses given are correct and complete to the best of my knowledge
and belief. I understand that falsification or omission of information may be
grounds for rejection or termination, in addition to any penalties provided by
law. I further agree to promptly inform all entities to which this form was
sent and not rejected of any change required to be updated by the Health Care Professional
Credentialing and Business Data Gathering Update Form.
I understand that this application does not entitle me to
participation in any hospital, health care entity, or health plan.
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Applicant's Signature
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Type or Print Name
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Date
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**PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE
ENTITY, AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN ATTESTATION AND
RELEASE OF INFORMATION.
Chapter A
PRACTICE
AND PROFESSIONAL INFORMATION
SECTION
A. GENERAL INFORMATION
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Name:
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Last
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First
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MI
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Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other
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List other names by which you have been known:
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Last
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First
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MI
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If you have been know by other names, please explain why
your name changed:
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Birth Date:
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Place of Birth:
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(mm/dd/yy)
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City
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State
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County
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Sex:
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Male
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Female
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Language Fluency of Applicant:
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English
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Other
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Spanish
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U.S. Citizen?
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Yes
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No
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If "no", do you have a legal right to reside
permanently and work in the U.S.?
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Yes
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No
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Resident Visa No:
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CONFIDENTIAL INFORMATION
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Social Security Number:
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Emergency Contact Person:
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Last
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First
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MI
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Telephone Number:
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( )
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Mailing Address:
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Daytime Phone:
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( )
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EMAIL Address:
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Fax Number:
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( )
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Check here if you have appended additional
information for this Section.
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SECTION
B. PROFESSIONAL INFORMATION
Illinois Professional
License Number:
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License Unlimited?
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Yes
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No
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If "no", please
explain limitation
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Current and Previous
Professional Licenses in Other States
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please
explain limitation
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please
explain limitation
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please
explain limitation
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Check here if you have appended
additional information for this section.
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Current Federal DEA License
Number:
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CONFIDENTIAL INFORMATION
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DEA License Number Expiration
Date:
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License Unlimited?
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Yes
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No
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(mm/dd/yy)
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If "no", please
explain limitation:
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Check here if you have
appended additional information for this section.
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Current and Previous State
Controlled Substance Numbers:
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CONFIDENTIAL INFORMATION
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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Please identify all
limitations related to the above Controlled Substances Numbers and explain limitations
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Medicare Unique Provider ID# (UPIN):
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National Provider Identification Number (NPI):
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Medicaid ID#:
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X-Ray Certification:
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State:
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Certificate #:
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Expiration Date:
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(mm/dd/yy)
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Check here if you have appended additional information
for this section.
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Specialty I:
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Are you Board Certified in Specialty I?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/yy)
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(mm/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/yy)
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Certification Expiration Date, If Any:
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(mm/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/yy)
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Specialty/Subspecialty II:
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Are you Board Certified in Specialty/Subspecialty II?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/yy)
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(mm/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/yy)
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Certification Expiration Date, If Any:
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(mm/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/yy)
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Specialty/Subspecialty III:
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Are you Board Certified in Specialty/Subspecialty III?
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Yes
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No
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Are you Board Certified in Specialty III?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/yy)
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(mm/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/yy)
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Certification Expiration Date, If Any:
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(mm/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/yy)
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Specialty/Subspecialty IV:
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Are you Board Certified in Specialty/Subspecialty IV?
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Yes
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No
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Are you Board Certified in Specialty IV?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/yy)
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(mm/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/yy)
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Certification Expiration Date, If Any:
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(mm/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/yy)
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Check here if you have appended additional information
for this section.
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Chapter A
SECTION
C. PROFESSIONAL LIABILITY INSURANCE
Please provide information on
all professional liability insurance carriers from whom you have received
coverage in the past 10 years.
CURRENT PROFESSIONAL
LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
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Address:
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Street
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City
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State
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Zip
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Policy Number:
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Original Effective Date:
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Expiration Date:
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(mm/dd/yy)
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(mm/dd/yy)
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Policy Limits:
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Per Occurrence:
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$
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Aggregate:
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$
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Retroactive Date:
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(mm/dd/yy)
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What type coverage do you have?
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Claims Made
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Occurrence
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Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
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Yes
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No
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PREVIOUS PROFESSIONAL LIABILITY INSURANCE
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CONFIDENTIAL INFORMATION:
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Carrier:
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Address:
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Street
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City
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State
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Zip
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Policy Number:
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Original Effective Date:
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Expiration Date:
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(mm/dd/yy)
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(mm/dd/yy)
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Policy Limits:
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Per Occurrence:
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$
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Aggregate:
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$
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Retroactive Date:
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(mm/dd/yy)
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What type coverage do you have?
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Claims Made
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Occurrence
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Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
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Yes
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No
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PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
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Address:
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Street
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City
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State
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Zip
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Policy Number:
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Original Effective Date:
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Expiration Date:
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(mm/dd/yy)
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(mm/dd/yy)
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Policy Limits:
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Per Occurrence:
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$
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Aggregate:
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$
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Retroactive Date:
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(mm/dd/yy)
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What type coverage do you have?
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Claims Made
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Occurrence
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Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
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Yes
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No
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PREVIOUS PROFESSIONAL LIABILITY INSURANCE
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CONFIDENTIAL INFORMATION:
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Carrier:
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Address:
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Street
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City
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State
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Zip
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Policy Number:
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Original Effective Date:
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Expiration Date:
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(mm/dd/yy)
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(mm/dd/yy)
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Policy Limits:
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Per Occurrence:
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$
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Aggregate:
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$
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Retroactive Date:
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(mm/dd/yy)
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What type coverage do you have?
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Claims Made
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Occurrence
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Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
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Yes
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No
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Check here if you have appended additional information
for this section.
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Chapter A
SECTION
D. EDUCATION AND TRAINING
If there are any gaps in
your training (greater than 30 days), or if you have not completed any portion
of your training, please explain on a separate sheet of paper and attach to
this application.
MEDICAL/PROFESSIONAL SCHOOL
Institution Name:
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Degree:
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Year Graduated:
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Dates attended:
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From:
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To:
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(mm/yy)
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(mm/yy)
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If you are a graduate of a foreign medical school, are you
certified by the Educational
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Commission for Foreign Medical Graduates (ECFMG)?
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Yes
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No
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Date Issued:
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Serial Number for ECFMG
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Were you the subject of any disciplinary action during
your time at this
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institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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If you attended more than one medical/professional school,
please check here and
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attach an explanation that duplicates the information
requested above:
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INTERNSHIP
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Type of internship:
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Rotating
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Straight
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If straight, please list specialty:
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Did you successfully complete this program?
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Yes
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No
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If “no”, please attach
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an explanation.
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If more than one internship, please check here and attach
additional information that duplicates
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the information requested above:
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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FIRST RESIDENCY
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Type of residency:
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Did you successfully complete this program?
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Yes
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No
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If “no”, please attach an
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explanation.
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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SECOND RESIDENCY
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From
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To:
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(mm/yy)
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(mm/yy)
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Type of residency:
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Did you successfully complete this program?
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Yes
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No
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If “no”, please attach an
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explanation.
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If more than two residencies, please check here and attach
additional information that duplicates the information requested above:
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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FIRST FELLOWSHIP
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Type of fellowship:
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Did you successfully complete this program?
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Yes
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No
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If “no”, please attach an
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explanation.
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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SECOND FELLOWSHIP
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Type of fellowship:
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Did you successfully complete this program?
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Yes
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No
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If “no”, please attach an
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explanation.
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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If more than two fellowships, please check here and attach
additional information that duplicates the information requested above:
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TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates:
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From:
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To:
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Rank/Position, if applicable:
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(mm/yy)
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(mm/yy)
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Were you the subject of any disciplinary action during
your time at this institution?
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Yes
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No
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(Attach an explanation of a “yes” answer.)
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TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)
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Institution Name:
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Department Chair or Program Director:
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Last
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First
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MI
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Degree
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Mailing Address:
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Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Dates:
|
From:
|
|
To:
|
|
Rank/Position, if applicable:
|
|
|
(mm/yy)
|
|
(mm/yy)
|
|
Were you the subject of any disciplinary action during
your time at this institution?
|
Yes
|
No
|
(Attach an explanation of a “yes” answer.)
|
If more than two teaching experiences/faculty
appointments, check here and attach additional information that duplicates
the information above:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MEMBERSHIP
STATUS – USE FOR SECTIONS E, F AND G
|
Please use the following key to indicate membership
status in sections E (Hospital Membership – Current and Pending), F
(Hospital Membership – Previous), and G (Ambulatory Surgical Treatment Center
Practice) below.
|
A.
|
Active
|
F.
|
Active Provisional Staff
|
K.
|
Pending
|
B.
|
Courtesy
|
G.
|
Senior Staff
|
L.
|
Other (Specify)
|
C.
|
Consulting
|
H.
|
Associate
|
|
|
D.
|
Adjunct
|
I.
|
Provisional
|
|
|
E.
|
Suspended/
|
J.
|
Affiliate
|
|
|
|
Terminated/
|
|
|
|
|
|
Resigned
|
|
|
|
|
Chapter A
SECTION E. HOSPITAL
MEMBERSHIP – CURRENT AND PENDING
Please list all hospitals at which you are a member of
the Medical Staff and have clinical privileges or have applications for
privileges pending. (Include additional sheets if more than three
hospitals.)
A.
|
Primary Hospital
|
|
|
Hospital Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
To Present
|
|
|
From (mm/yy)
|
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
|
Any limitations in your area of specialty at this
hospital?
|
|
|
|
|
|
B.
|
Other Hospital
|
|
|
|
Hospital Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
To Present
|
|
|
From (mm/yy)
|
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
|
Any limitations in your area of specialty at this
hospital?
|
|
|
|
|
|
C.
|
Other Hospital
|
|
|
|
Hospital Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
To Present
|
|
|
From (mm/yy)
|
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
|
Any limitations in your area of specialty at this
hospital?
|
|
Check here if you have appended additional information
for this section
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter A
SECTION F. HOSPITAL
MEMBERSHIP – PREVIOUS
Please list all hospitals where you previously held
privileges other than during your Internship/Residency/Fellowship. Use the
membership status key listed prior to Section E. (Include additional sheets
if more than three hospitals.)
1.
|
Hospital Name
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
From (mm/yy)
|
To (mm/yy)
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
|
|
|
|
2.
|
Hospital Name
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
From (mm/yy)
|
To (mm/yy)
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
|
|
|
|
3.
|
Hospital Name
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
From (mm/yy)
|
To (mm/yy)
|
|
Department/Division:
|
|
Medical Staff Office FAX #:
|
( )
|
|
Department Telephone #:
|
( )
|
|
Check here if you have appended additional information
for this section
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter A
SECTION G. AMBULATORY
SURGICAL TREATMENT CENTER PRACTICE
Please list all ambulatory surgical treatment centers
where you currently have clinical privileges. Use the Membership Status key
listed prior to Section E. (Include additional sheets if more than three
ASTCs.)
A.
|
Primary Ambulatory Surgical
Treatment Center
|
|
ASTC Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
FAX#:
|
( )
|
Telephone #:
|
( )
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
|
From (mm/yy)
|
|
To (mm/yy)
|
B.
|
Other Ambulatory Surgical Treatment Center
|
|
ASTC Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
FAX#:
|
( )
|
Telephone #:
|
( )
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
|
From (mm/yy)
|
|
To (mm/yy)
|
C.
|
Other Ambulatory Surgical Treatment Center
|
|
ASTC Name:
|
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
FAX#:
|
( )
|
Telephone #:
|
( )
|
|
Membership Status (see above):
|
|
Dates:
|
|
|
|
|
|
|
From (mm/yy)
|
|
To (mm/yy)
|
Check here if you have appended additional information
for this section.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter A
SECTION H. WORK
HISTORY
List chronologically (most recent first) all work
engagements (including employment, self-employment, service as an independent
contractor, and military service) in the past 4 years. Do not duplicate
internship, residency, and fellowship information previously reported. If there
is any gap of greater than 30 days in chronology, explain it on a separate
page.
Current work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To Present
|
|
|
(mm/yy)
|
|
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
|
|
|
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
|
(mm/yy)
|
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
Previous work place:
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Title or Professional Occupation:
|
|
Time in this employment:
|
From:
|
|
To:
|
|
|
|
(mm/yy)
|
|
(mm/yy)
|
|
Check here if you have appended additional information
for this section.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter A
SECTION I. PROFESSIONAL
REFERENCES
Please list the names of three individuals who have
personal knowledge (within the past 12 months) of your current clinical
abilities, ethical character and interpersonal skills and who would be willing
to provide this information upon request. Do not list partners or department
chairpersons. Do not list relatives or people listed elsewhere in this
credentialing form.
CONFIDENTIAL INFORMATION
1.
|
Name:
|
|
Title:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
|
Specialty:
|
|
|
|
Mailing Address:
|
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Relationship:
|
|
Years Known:
|
|
2.
|
Name:
|
|
Title:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
|
Specialty:
|
|
|
|
Mailing Address:
|
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Relationship:
|
|
Years Known:
|
|
3.
|
Name:
|
|
Title:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
|
Specialty:
|
|
|
|
Mailing Address:
|
|
|
|
Street
|
City
|
State
|
Zip
|
Telephone Number:
|
( )
|
Fax Number:
|
( )
|
Relationship:
|
|
Years Known:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter A
SECTION J. PROFESSIONAL
HISTORY: CONFIDENTIAL
Submit with all applications. Please answer the following
questions to the best of your knowledge with a "yes" or "no".
If you answer "yes" to any questions, please complete FORM A. Please
make copies of FORM A as needed and complete one form for each "yes"
answer.
Adverse or Other Actions
1.
|
Has your license to practice in any jurisdiction ever been
denied, restricted, limited, suspended, revoked, canceled and/or subject to
probation, either voluntarily or involuntarily, or has your application for a
license ever been withdrawn?
|
|
Yes
|
|
No
|
2.
|
Have you ever been reprimanded and/or fined, been the
subject of a complaint, and/or been notified in writing that you have been
investigated as the possible subject of a criminal, civil or disciplinary
action by any state or federal agency that licenses providers?
|
|
Yes
|
|
No
|
3.
|
Have you lost any board certifications, and/or failed to
recertify?
|
|
Yes
|
|
No
|
4.
|
Have you been examined by a Certifying Board but failed to
pass?
|
|
Yes
|
|
No
|
5.
|
Has any information pertaining to you, including
malpractice judgements and/or disciplinary action, ever been reported to the
National Practitioner Data Bank (NPDB) and/or any other practitioner data
bank?
|
|
Yes
|
|
No
|
6.
|
Has your federal DEA number and/or state controlled
substances license been restricted, limited, relinquished, suspended or
revoked, either voluntarily or involuntarily, and/or have you ever been
notified in writing that you are being investigated as the possible subject
of a criminal or disciplinary action with respect to your DEA or controlled
substance registration?
|
|
Yes
|
|
No
|
7.
|
Have you or any of your hospital or ambulatory surgical
treatment center (ASTC) privileges and/or membership been denied, revoked,
suspended, reduced, placed on probation, proctored, placed under mandatory consultation
or non-renewed?
|
|
Yes
|
|
No
|
8.
|
Have you voluntarily or involuntarily relinquished or
failed to seek renewal of your hospital or ASTC privileges for any reason?
|
|
Yes
|
|
No
|
9.
|
Have any disciplinary actions or proceedings been instituted
against you and/or are any disciplinary actions or proceedings now pending
with respect to your hospital or ASTC privileges and/or your license?
|
|
Yes
|
|
No
|
10.
|
Have you ever been reprimanded, censured, excluded,
suspended and/or disqualified from participating in Medicare, Medicaid,
CHAMPUS and/or any other governmental health-related programs, or voluntarily
withdrawn to avoid an investigation relating to those programs?
|
|
Yes
|
|
No
|
11.
|
Have Medicare, Medicaid, CHAMPUS or PRO authorities,
and/or any other third party payors, brought charges against you for alleged
inappropriate fees and/or quality-of-care issues?
|
|
Yes
|
|
No
|
12.
|
Have you been denied membership and/or been subject to
probation, reprimand, sanction or disciplinary action, or have you ever been notified
in writing that you are being investigated as the possible subject of a
criminal or disciplinary action by any health care organization, e.g.,
hospital, HMO, PPO, IPA, professional group or society, licensing board,
certification board, PSRO, or PRO?
|
|
Yes
|
|
No
|
13.
|
Have you withdrawn an application or any portion of an
application for appointment or reappointment for clinical privileges or staff
appointment or for a license or membership in an IPA, PHO, professional group
or society, health care entity or health care plan prior to a final decision
to avoid a professional review or an adverse decision?
|
|
Yes
|
|
No
|
PROFESSIONAL LIABILITY ACTIONS
If you answer "yes" to any questions in this
section, please complete FORM B. Please make copies of FORM B, if needed, and
complete one for each "yes" answer.
|
|
|
|
|
|
1.
|
Have any professional liability judgements ever been
entered against you?
|
|
Yes
|
|
No
|
2.
|
Have any professional liability claim settlements ever
been paid by you and/or paid on your behalf?
|
|
Yes
|
|
No
|
3.
|
Are there any currently pending professional liability
suits, actions and/or claims filed against you?
|
|
Yes
|
|
No
|
4.
|
Has any person or entity ever been sued for your clinical
actions?
|
|
Yes
|
|
No
|
LIABILITY INSURANCE
If you answer "yes" to this question, please
complete FORM C.
|
Have you ever been denied or voluntarily relinquished your
professional liability insurance coverage, and/or have had your professional
liability insurance coverage canceled or non-renewed or limits reduced?
|
|
Yes
|
|
No
|
CRIMINAL ACTIONS
If you answer "yes" to any questions in this
section, please complete FORM D. Please make copies of FORM D, if needed, and
complete one for each "yes" answer
1.
|
Have you been charged with or convicted of a crime (other
than a minor traffic offense) in this or any other state or country and/or
do you have any criminal charges pending other than minor traffic offenses in
this State or any other state or country?
|
|
Yes
|
|
No
|
2.
|
Have you been the subject of a civil or criminal complaint
or administrative action or been notified in writing that you are being
investigated as the possible subject at a civil, criminal or administrative
action regarding sexual misconduct, child abuse, domestic violence or elder
abuse?
|
|
Yes
|
|
No
|
MEDICAL CONDITION
If you answer "yes" to this question, please
complete FORM E.
Do you have a medical condition, physical defect or
emotional impairment that in any way impairs and/or limits your ability to
practice medicine with reasonable skill and safety?
|
|
Yes
|
|
No
|
CHEMICAL SUBSTANCES OR ALCOHOL ABUSE
|
If you answer "yes" to any questions in this
section, please complete FORM F. Please make copies of FORM F, if needed, and
complete one for each "yes" answer.
|
1.
|
Are you currently engaged in illegal use of any legal or
illegal substances?
|
|
Yes
|
|
No
|
2.
|
Do you currently overuse and/or abuse alcohol or any other
controlled substances?
|
|
Yes
|
|
No
|
3.
|
If you use alcohol and/or chemical substances, does your
use in any way impair and/or limit your ability to practice medicine with
reasonable skill and safety?
|
|
Yes
|
|
No
|
4.
|
Are you currently participating in a supervised
rehabilitation program and/or professional assistance program that monitors
you for alcohol and/or substance abuse?
|
|
Yes
|
|
No
|
INVESTMENTS
|
In the last 5 years have you and/or a member of your
family purchased or made an investment in (other than securities of a
publicly traded company), or otherwise have a business interest in any
clinical laboratory, diagnostic or testing center, hospital, surgicenter,
and/or other business dealing with the provision of ancillary health
services, equipment or supplies?
|
|
Yes
|
|
No
|
If "yes", please provide explanation:
|
|
|
|
|
|
|
|
|
|
|
|
Chapter B
SECTION K. PRIMARY
SITE INFORMATION
Please provide the following information for the primary
site at which you practice.
|
|
Primary Site
|
Group/Business Name
|
|
Building Name
|
|
Office Address – Number and Street – Suite
|
|
City
|
County
|
State
|
Zip
|
|
( )
|
|
|
|
Main Telephone Number
|
|
Office Administrator –
|
Last
|
First
|
MI
|
|
( )
|
|
( )
|
|
|
|
Beeper Number
|
|
Fax Number
|
|
E-Mail
|
|
( )
|
|
( )
|
|
Emergency Number
|
|
Answering Service
|
|
Specialty practiced at this site:
|
|
|
Is your practice restricted within your specialty (e.g.,
by age or type of patient)?
|
|
Yes
|
No
|
If "yes", describe the restrictions:
|
|
|
|
Briefly describe your practice
at this location, including any special practice focus or
|
equipment:
|
|
|
|
Are you
currently accepting new patients at this location?
|
Yes
|
No
|
|
If "yes", describe any restrictions (e.g.,
appointment type, patient type):
|
|
|
|
|
|
Please provide the number of active patients enrolled with
you at this site:
|
|
|
Please provide the number of patient visits you have at
this site per year:
|
|
|
Indicate your office schedule at this location in the
following table. Write your specific hours in the appropriate spaces for
each day.
|
|
Monday
|
Tuesday
|
Wednesday
|
Thursday
|
Friday
|
Saturday
|
Sunday
|
Hours:
|
|
Please indicate standard patient waiting times to
schedule an appointment at this site for:
|
|
|
New Patient
|
Existing Patient
|
|
Emergency
Care
|
|
|
|
|
|
|
|
|
Urgent
Care
|
|
|
|
|
|
|
|
|
Symptomatic
Care (e.g., sore throat)
|
|
|
|
|
|
|
|
|
Routine
Visits (e.g., blood pressure check)
|
|
|
|
|
|
|
|
|
Preventative
Routine Care (e.g., school or annual physical)
|
|
|
|
|
|
|
|
Please provide the following regarding your practice at
this site:
|
|
Maximum
Number of Appointments per Hour
|
|
|
Average
Waiting Time in Office (from scheduled
appointment time to actual
examination)
|
|
|
Average
Response Time for Returning Patient Calls:
|
Acute or Urgent Situation:
|
|
|
|
Emergency Situation:
|
|
|
|
Routine Call:
|
|
Please check all procedures you perform at this site:
|
|
Age-appropriate immunizations
|
EKG
|
Drawing blood
|
|
Tympanometry/ audiometry screening
|
X-rays
|
Minor surgery
|
|
Pulmonary function studies
|
Flexible sigmoidoscopy
|
Laceration repair
|
|
Office gynecology (routine pelvic/PAP)
|
Asthma treatment
|
Allergy
skin testing
|
|
Osteopathic/chiropractic manipulation
|
IV hydration/ treatment
|
Physical therapy
|
List any special skills or qualifications you or your
office staff have that enhance your ability to practice medicine or treat
certain patients or classes of patients. List separately any special language
skills, such as fluency in a foreign language or proficiency in sign
language.
|
|
Special Skills of Practitioner:
|
|
|
Special Skills of Staff:
|
|
|
Languages Spoken by Practitioner:
|
|
|
Languages Written by Practioner:
|
|
|
Languages Spoken by Staff:
|
|
|
Languages Written by Staff:
|
|
Is this practice site handicapped accessible (check
all that apply)?
|
|
Building
|
Parking
|
Wheelchair
|
Restroom
|
Does this site employ
paraprofessionals for direct patient care?
|
Yes
|
No
|
If "yes", is supervision always provided on
premises during paraprofessional's direct patient
|
care?
|
Yes
|
No
|
Do the paraprofessionals bill under any of your Tax ID
Numbers?
|
Yes
|
No
|
|
CONFIDENTIAL INFORMATION: If
"yes", list Tax ID Numbers used:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Lab service at this site:
|
Yes
|
No
|
If "yes", check whether:
|
|
Primary
|
Secondary
|
Tertiary
|
|
CLIA Waiver:
|
Yes
|
No
|
CLIA Expiration Date:
|
|
Please provide the following information about physicians/practitioners
who provide coverage for patients enrolled at this site when you are not
available.
|
Name:
|
|
|
Last
|
First
|
MI
|
Degree
|
Specialty:
|
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
|
Name:
|
|
|
Last
|
First
|
MI
|
Degree
|
Specialty:
|
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
|
Name:
|
|
|
Last
|
First
|
MI
|
Degree
|
Specialty:
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
Name:
|
|
|
Last
|
First
|
MI
|
Degree
|
Specialty:
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
|
Please provide the following information about
physicians/practitioners who practice in this office:
|
|
Name:
|
|
Specialty:
|
|
|
|
|
Last
|
First
|
MI
|
|
|
|
|
Name:
|
|
Specialty:
|
|
|
|
|
Last
|
First
|
MI
|
|
|
|
|
Name:
|
|
Specialty:
|
|
|
|
|
Last
|
First
|
MI
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter B
SECTION L.
PRIMARY SITE TAX INFORMATION
Please provide the following information for your Primary
Site. Include tax information for each business arrangement you use at this
site. (Please include additional sheets if more than four applicable
business arrangements.)
Business Arrangement #1
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #2
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #3
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #4
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
|
|
|
|
|
Chapter B
SECTION M. ADDITIONAL
SITE INFORMATION
Please provide the following information for each
additional site at which you practice. If there is more than one additional
site, copy and complete this section for each additional site.
|
|
Site
|
Group/Business Name
|
|
Building Name
|
|
Office Address – Number and Street – Suite
|
|
City
|
County
|
State
|
Zip
|
|
( )
|
|
|
|
Main Telephone Number
|
|
Office Administrator –
|
Last
|
First
|
MI
|
|
( )
|
|
( )
|
|
|
|
Beeper Number
|
|
Fax Number
|
|
E-Mail
|
|
( )
|
|
( )
|
|
Emergency Number
|
|
Answering Service
|
|
Specialty practiced at this site:
|
|
|
|
Is your practice restricted within your specialty (e.g.,
by age or type of patient)?
|
|
|
Yes
|
No
|
If "yes", describe the restrictions:
|
|
|
|
|
|
Briefly describe your practice
at this location, including any special practice focus or
|
|
equipment:
|
|
|
|
|
|
Are you currently accepting new
patients at this location?
|
Yes
|
No
|
|
|
If "yes", describe any restrictions (e.g.,
appointment type, patient type):
|
|
|
|
|
|
|
|
|
Please provide the number of active patients enrolled with
you at this site:
|
|
|
|
Please provide the number of patient visits you have at
this site per year?
|
|
|
Indicate your office schedule at this location in the
following table. Write your specific hours in the appropriate spaces for
each day.
|
|
|
Monday
|
Tuesday
|
Wednesday
|
Thursday
|
Friday
|
Saturday
|
Sunday
|
|
Hours:
|
|
|
Please indicate standard patient waiting times to
schedule an appointment at this site for:
|
|
|
|
New Patient
|
Existing Patient
|
|
|
Emergency
Care
|
|
|
|
|
|
|
|
|
Urgent
Care
|
|
|
|
|
|
|
|
|
Symptomatic
Care (e.g., sore throat)
|
|
|
|
|
|
|
|
|
Routine
Visits (e.g., blood pressure check)
|
|
|
|
|
|
|
|
|
Preventative
Routine Care (e.g., school or annual physical)
|
|
|
|
|
|
|
|
Please provide the following regarding your practice at
this site:
|
|
|
Maximum
Number of Appointments per Hour
|
|
|
|
Average
Waiting Time in Office (from scheduled
appointment time to actual
examination)
|
|
|
|
|
|
Average
Response Time for Returning Patient Calls:
|
Acute or Urgent Situation:
|
|
|
|
|
Emergency Situation:
|
|
|
|
|
Routine Call:
|
|
|
Please check all procedures you perform at this site:
|
|
|
Age-appropriate immunizations
|
EKG
|
Drawing blood
|
|
|
Tympanometry/audiometry screening
|
X-rays
|
Minor surgery
|
|
|
Pulmonary function studies
|
Flexible sigmoidoscopy
|
Laceration repair
|
|
|
Office gynecology (routine pelvic/PAP)
|
Asthma treatment
|
Allergy skin testing
|
|
|
Osteopathic/chiropractic manipulation
|
IV hydration/ treatment
|
Physical therapy
|
|
|
Acupuncture
|
|
|
|
List any special skills or qualifications you or your
office staff have that enhance your ability to practice medicine or treat
certain patients or classes of patients. List separately any special language
skills, such as fluency in a foreign language or proficiency in sign
language.
|
|
Special Skills of Practitioner:
|
|
|
|
Special Skills of Staff:
|
|
|
Languages Spoken by Practitioner:
|
|
|
Languages Written by Practitioner:
|
|
|
Languages Spoken by Staff:
|
|
|
Languages Written by Staff:
|
|
Is this practice site handicapped accessible (check
all that apply)?
|
|
|
Building
|
Parking
|
Wheelchair
|
Restroom
|
|
Does this site employ paraprofessionals for direct
patient care?
|
Yes
|
No
|
|
If "yes", is supervision always provided on
premises during paraprofessional's direct patient
|
|
care?
|
Yes
|
No
|
|
Do the paraprofessionals bill under any of your Tax ID
Numbers?
|
Yes
|
No
|
|
CONFIDENTIAL INFORMATION: If
"yes", list Tax ID Numbers used:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Lab service at this site:
|
Yes
|
No
|
If "yes", check whether:
|
|
|
Primary
|
Secondary
|
Tertiary
|
|
|
CLIA Waiver:
|
Yes
|
No
|
CLIA Expiration Date:
|
|
|
Please provide the following information about
physicians/practitioners who provide coverage for patients enrolled at this
site when you are not available.
|
Name:
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
|
Name:
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
|
Name:
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
Name:
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
Degree
|
|
Address:
|
|
Telephone:
|
( )
|
|
Street
|
City
|
State
|
Zip
|
|
Availability:
|
Days
|
Nights
|
Weekends
|
Holidays
|
CONFIDENTIAL INFORMATION: Tax ID#:
|
|
Please provide the following information about
physicians/practitioners who practice in this office:
|
Name
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
|
Name
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
|
Name
|
|
Specialty:
|
|
|
Last
|
First
|
MI
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chapter B
SECTION N.
ADDITIONAL SITE TAX INFORMATION
Please provide the following information for each
additional site at which you practice. Include tax information for each
business arrangement you use at this site. (If there is more than one
additional site or more than 5 business arrangements at any one site, please
copy and complete this page for each additional site and business arrangement.)
Business Arrangement #1
|
Site #:
|
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #2
|
Site #:
|
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #3
|
Site #:
|
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
Business Arrangement #4
|
Site #:
|
|
Name of Business Arrangement on SS4 or W-9 Form:
|
|
Type of Arrangement (e.g., solo or group practice, IPA,
PHO):
|
|
CONFIDENTIAL INFORMATION: Tax ID for this
Arrangement:
|
|
Billing Address, if Different from Primary Site:
|
|
Telephone Number, if Different from Primary Site:
|
( )
|
|
|
|
|
|
|
|
|
|
End Uniform Health Care and Hospital CredentialsCredentialing and Business Data Gathering
Form.
Attach Forms A-F As Required.
FORM A – ADVERSE
AND OTHER ACTIONS
DUPLICATE this form as necessary to complete separate
sheet for EACH occurrence that applies. Use reverse side of this form if
additional space is needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
Indicate the number of ONE of the questions in Section J
to which you answered "yes":
|
Question Number:
|
|
|
|
A.
|
Describe the circumstances surrounding this occurrence.
Please include the date of the occurrence.
|
|
|
|
|
|
|
|
|
|
|
|
|
B.
|
Provide an explanation of any actions taken. Please
include the date the action was taken.
|
|
|
|
|
|
|
|
|
|
|
|
|
C.
|
Provide the current status of the issue.
|
|
|
|
|
|
|
|
|
|
|
D.
|
If known:
|
Contact:
|
|
|
|
|
Department/Committee:
|
|
|
|
Address:
|
|
|
|
|
Street
|
City
|
State
|
Zip
|
|
|
Telephone Number:
|
( )
|
|
|
|
|
|
Signature:
|
|
Date:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FORM B – PROFESSIONAL
LIABILITY ACTIONS
DUPLICATE this form as necessary to complete a separate
sheet for EACH action
or allegation. Use reverse side of this form if
additional space is needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
A.
|
Plaintiff’s Name:
|
|
|
|
Last
|
First
|
MI
|
|
If court case, Case Name & Case Number:
|
|
|
|
B.
|
Your Involvement in the Care (Attending, Consulting, Etc.):
|
|
C.
|
Your Status in the Case (Sole Defendant, Co-Defendant,
Ownership Interest in
|
|
Provider Practice Named in Suit, Etc.)
|
|
D.
|
Allegations, including Patient Outcome, If Available:
|
|
|
|
|
|
|
|
E.
|
Date of Incident (mm/yy)
|
|
F.
|
Date Filed (mm/yy)
|
|
G.
|
Date Case Closed (mm/yy):
|
|
|
|
Case Resolution:
|
|
|
Dismissed
|
|
Judgement
|
|
Arbitration
|
|
Other
|
|
|
Settlement Out of Court
|
|
Pending
|
|
Mediation
|
|
|
H.
|
Amount Paid on Your Behalf (if any): $
|
|
|
I.
|
Professional Liability Insurer Name (if one was involved):
|
|
J.
|
Insurer Telephone Number:
|
( )
|
K.
|
Policy Number:
|
|
L.
|
Insurer Address (Street, City, State, Zip Code):
|
|
|
|
Signature:
|
|
Date:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FORM C – LIABILITY
INSURANCE
DUPLICATE this form as necessary to complete a separate
sheet for EACH action or allegation. Use reverse side of this form if
additional space is needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
A.
|
History of Professional Liability Insurance (Please
Check One)
|
|
|
Cancelled Voluntarily
|
|
Non-Renewed
|
|
|
Cancelled Involuntarily
|
|
Application Denied
|
B.
|
Carrier Name:
|
|
C.
|
Carrier Telephone Number:
|
( )
|
D.
|
Policy Number:
|
|
|
E.
|
Carrier Address:
|
|
|
|
Street
|
City
|
State
|
Zip
|
F.
|
Dates of Coverage:
|
From (mm/yy):
|
|
To (mm/yy):
|
|
|
|
|
G.
|
Circumstances Involved:
|
|
|
|
Signature:
|
|
Date:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FORM D – CRIMINAL
ACTIONS
DUPLICATE this form as necessary to complete a separate
sheet for EACH incident. Use reverse side of this form if additional space is
needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
A.
|
Date of Incident (mm/yy):
|
|
|
B.
|
Date of Complaint or Conviction (mm/yy):
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C.
|
Date of Resolution (mm/yy):
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D.
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Type of Resolution (Dismissed, Plea Bargain, Misdemeanor,
Felony):
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E.
|
Allegations:
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F.
|
Details of Incident:
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G.
|
Actions Taken Against You:
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|
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H.
|
Current Status of Situation:
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I.
|
Medical Practice Privileges Affected as a Result of This
Situation:
|
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Signature:
|
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Date:
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FORM E – MEDICAL
CONDITION
DUPLICATE this form as necessary to complete a separate
sheet for EACH condition. Use reverse side of this form if additional space is
needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
A.
|
Describe this medical condition:
|
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|
|
|
|
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|
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B.
|
To what extent does or could this condition affect your
current ability to practice
|
|
medicine in your specialty area or to perform a full range
of clinical activities?
|
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|
|
|
|
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|
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C.
|
What is the current status of your condition?
|
|
|
|
|
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|
|
|
|
D.
|
Provide the name and address of your personal
physician/health care provider who can provide information about your health
condition.
|
|
Name
|
Telephone Number
|
|
|
|
( )
|
|
Last
|
First
|
MI
|
Degree
|
|
|
|
|
|
( )
|
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Last
|
First
|
MI
|
Degree
|
|
|
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Signature:
|
|
Date:
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|
FORM F – CHEMICAL
SUBSTANCES OR ALCOHOL ABUSE
DUPLICATE this from as necessary to complete a separate
sheet for EACH chemical substance incident. Use reverse side of this form if
additional space is needed.
Applicant Name:
|
|
|
Last
|
First
|
MI
|
Describe the substance you use:
|
|
|
A.
|
To what extent does, or could, your use of this substance
affect your current ability to practice medicine in your specialty area or to
perform a full range of clinical activities?
|
|
|
|
|
|
|
B.
|
Monitored by State Board Mandate (Name and Address)
|
|
|
|
|
|
|
|
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C.
|
Monitored Voluntarily (Name and Address)
|
|
|
|
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|
|
|
|
D.
|
Other information about the current status of your use of
substances:
|
|
|
|
|
E.
|
Abstinent since (mm/yy):
|
|
|
|
|
F.
|
Provide the name and address of your personal
physician/health care provider who can provide information about your
treatment for alcohol or chemical substance use and can comment on what
impact (if any) it has on your current/future professional practice.
|
|
Name:
|
|
|
|
Last
|
First
|
MI
|
Degree
|
|
Address:
|
|
|
Street
|
City
|
State
|
Zip
|
|
|
|
Telephone Number:
|
( )
|
|
|
|
Signature:
|
|
Date:
|
|
|
|
|
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