DOCUMENTS CHECKLIST CRNA
|
|
- Asher Lloyd
- 8 years ago
- Views:
Transcription
1 DOCUMENTS CHECKLIST CRNA Please include clear copies of the following documents with completed application: o Application Form Initialed, signed and dated o Release and Authorization Form Signed and dated o Skills Checklist Signed and dated o Three Peer References Completed by CRNA/MD o Copy of Curriculum Vitae Must include a complete chronological list of activities since graduation detailed by Month and Year o Gaps larger than 30 days in chronology must be accounted for o If you are a locum tenens provider, your CV must reflect ALL Locum Assignments o Copy of Current Malpractice Binder Or list of carries from the past 5 years o Additional Documentation - As requested pertaining to any questions answered in the affirmative under Professional Liability and Disciplinary Action. o Copies of ALL State Licenses o Copy of Nursing and Anesthesia diplomas o Copy of AANA/CRNA/CCNA Certification Cards o Copy of NPI Letter o Medicare/Medicaid/Blue Cross Numbers o Copy of Current CME s From the past 24 months o Copy of Current BLS, ACLS, PALS All that are applicable o Copy of Immunization Records PPD/TB or Chest X-Ray, Rubella, Rubeola, Measles, Mumps, Hepatitis B, Varicella o Drivers License Clear, color copy o Recent Photo Passport size preferred; jpg format if possible Rhino Medical Services 2000 East Lamar Boulevard # 250 Arlington, TX Phone: (866) Fax: (800) consultants@rhinomedical.com
2 Skills Checklist: General Anesthesia & Analgesia Preoperative evaluation Inhalation agents Sevoflurane Desflurane Isoflurane Intramuscular agents Regional Anesthesia Topical Infiltration Interthecals Spinal Hypobaric Hyperbaric Bier blocks Field blocks Other peripheral blocks Transtracheal blocks Epidurals Axillary blocks Eye blocks Intracapsular Retrobulbar Peribulbar Interscalene blocks Intercostal Intravenous administration of: Crystalloids Blood Blood by-products Colloids Procedures Peripheral IV placement Central line placement Internal jugular Subclavian Central line monitoring External jugular line placement Arterial line placement Arterial line monitoring Swan ganz catheterization and monitoring Cardiac output monitoring Mechanical ventilation Resuscitation techniques and therapy Defibrillation External cardiac pacing Emergency Management (airway/dysrhythmia/vital signs) in OR and PACU Cardiopulmonary bypass techniques Autotransfusion techniques Hypotensive techniques Hypothermia techniques Fiberoptic intubation Endotracheal intubation LMA placement ICP monitoring Special Categories Diagnostic and therapeutic blocks Steroid blocks Spinals-differential Sympathetic blocks (Continued on next page) Initials
3 Skills Checklist: Drugs Alpha blockers Beta blockers Anticoagulants Anticoagulant antagonists Barbiturates Cardiac drugs Antiemetics Diuretics Dissociative agents Hypnotics Muscle relaxants Muscle relaxant reversal agents Narcotic antagonists Parasympathomimetics Parasympatholytics Steroids Sympathomimetics Tranquilizers Non-narcotic analgesics Vasoactive Specialties or Specific Skills Neuro Cardiac Thoracic Transplants Urology GYN ENT Eyes OB Major Vascular Burns Pediatrics Neonates Geriatrics Comments Provider Printed Name Provider Signature CONSENT OF MEDICAL STAFF APPLICANTS I hereby affirm that the information provided by me on this application and attachments is true, complete and correct, and that Rhino Medical Services will rely on the truthfulness of my statements in evaluating my potential as a Rhino Medical Services Provider. I hereby release from liability Rhino Medical Services, its staff and representatives for their acts performed in good faith and without malice in connection with evaluation of my application, credentials and qualifications. I further release from liability physicians, hospital and other references for the good faith release of information regarding my professional capabilities and performances, and agree that other sources not listed by me may be contacted. I further acknowledge that (a) the decision to offer me contractual work with Rhino Medical Services is solely at the discretion of Rhino Medical Services, (b) any information received from references by Rhino Medical Services may not be released to me without the consent of the reference, and (c) I agree that I will not enter into an arrangement to provide temporary or permanent CRNA services with any individual, group or institution to whom I am referred by Rhino Medical Services, except through Rhino Medical Services, or with written Rhino Medical Services consent. Provider Signature
4 Application for Appointment to Medical Staff IDENTIFYING INFORMATION (FOR INTERNAL PURPOSES ONLY) LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME SOCIAL SECURITY NUMBER HOME ADDRESS CITY STATE ZIP CODE HOME TELEPHONE COUNTY ADDRESS MOBILE TELEPHONE BIRTHPLACE MARITAL STATUS MALE FEMALE DATE OF BIRTH CITIZENSHIP NPI NUMBER NAME OF SPOUSE EMERGENCY CONTACT PHONE NUMBER M S W D DESIRED WORK SITUATION Available Preferred Assignment Length Maximum Travel Distance Full Time Part Time Over Time Call Weekends FACILITY PREFERENCES Small Hospital Medium Hospital University Hospital Trauma Office Surgery Center Supervised Solo Either UNDERGRADUATE TRAINING COLLEGE OR UNIVERSITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) COLLEGE OR UNIVERSITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) GRADUATE TRAINING COLLEGE/UNIVERSITY/FACILITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) NATIONAL CERTIFICATION ARE YOU CURRENTLY CERTIFIED? DATE OF ORIGINAL CERTIFICATION NAME OF CERTIFICATION ONLY ANSWER IF NOT CURRENTLY CERTIFIED Have you ever taken the national examination and failed to pass? If yes, how many times? Have you applied for the certification exam? If yes, when are you scheduled to take the exam? EXAMINATIONS/REGISTRATION LICENSES SBTPE NCLEX State Constructed Number of times taken? Last Taken? PROFESSIONAL REFERENCES (please complete in full) Either CRNA/MD 1. Name Phone 2. Name Phone 3. Name Phone
5 Health Status Questionnaire Preliminary consideration of professional staff appointment/reappointment has been extended to you. The position and clinical privileges you have requested require you to demonstrate that your physical and mental condition is adequate to perform the duties of the position and/or to exercise the prerogatives of professional staff membership. As a first step to demonstrating this capacity, please provide responses to the following questions. Any YES answer will not automatically disqualify you from locum tenens and/or professional staff appointment. 1. Do you have any physical or mental disabilities which would interfere with your professional duties or in any way impose a risk to patients, members, or yourself? If yes, please state or describe any reasonable accommodations that can be made to enable you to safely and efficiently perform the duties and avoid risk to others. 2. Are you currently using any controlled substances? If yes, please describe. 3. Are you now or have you ever been treated or received institutional care for any chronic / recurring illnesses, alcoholism, or other chemical dependency? If yes, please describe and accompany with a letter from the treating physician/institution stating dates, results, and current status. 4. Have you had a positive Rubella Titer? If yes, what date? 5. Have you had a positive Rubeola Titer? If yes, what date? 6. Have you ever received Rubeola Vaccine? If yes, what date? 7. Have you had a Varicella Titer? If yes, what date? 8. Have you had a Purified Protein Derivative Test within the last year? If yes, what was the result? If the test was positive, please attach results of a base line chest x-ray less than 5 years old. 9. Have you had a Hepatitis B antigen antibody test? If yes, what date, and what were the results? If the results were negative, or you have not had such a test, please consult infection control to discuss obtaining Hepatitis screening and/or immunization consultation. Comments: Provider Signature
6 FITNESS FOR POSITION If you answer yes to question #3 or #4, provide a full explanation on a separate sheet 1. The essential function of a healthcare provider is to offer a standard of care that is acceptable within his/her specialty. Are you capable of performing this function with or without reasonable accommodations? 2. Are you authorized to work as an independent contractor in the United States? 3. Are you currently abusing alcohol, using any illegal drugs, or failing to take legally prescribed drugs in the manner prescribed? 4. Have you abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed in the past? If yes, which drugs, and how recently? PROFESSIONAL LIABILITY If you answer yes to any of the following, provide full explanation on a separate sheet 1. Have any malpractice claims, suits, settlements or arbitration proceedings been made against you? 2. Are there any claims, suits, or settlements pending against you or any professional entity in which you are a member? If you answered YES to any of these questions, please include a personal summary on each case to include: year occurred, status closed, etc.), settlement amount, detail of the case, malpractice carrier. (i.e., pending, In addition to your summary of events, please include any and all additional documentation available from attorneys, and/or malpractice carriers. DISCIPLINARY ACTIONS Any YES answer will not automatically disqualify you from consideration for placement on Rhino Medical Services roster of eligible providers. 1. Have you ever been convicted of a felony or a misdemeanor? 2. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? 3. Have you ever been denied or surrendered a state or federal controlled substances certificate? 4. Has your license to practice medicine in any state been reprimanded, sanctioned, placed on probation, curtailed, suspended, revoked, restricted, denied or voluntarily surrendered? 5. Have you ever been denied a certificate by, or the privilege of taking an examination before, any state medical board? 6. Have your staff/clinical privileges at any hospital, healthcare facility, or clinic been denied, revoked, suspended, curtailed, limited, or placed under conditions restricting your practice? 7. Have you ever been terminated from employment? 8. Have you ever been disciplined by any state board for any violation of the Medical Practice Act or unethical conduct? 9. Have you ever been denied provider participation in any state or federal Medicare of Medicaid programs? 10. Have you ever been terminated, sanctioned, penalized or had to repay money to any state or federal Medicare/Medicaid programs? 11. Have you ever been the subject of any investigative or disciplinary proceedings or reprimanded by a governmental or administrative agency? 12. Have you ever been convicted of a violation of any federal or state narcotic laws? 13. Have you ever been disciplined by a hospital staff, internship or residency program? 14. Is there any other issue, which should be disclosed that may have an adverse impact on your ability to deliver effective healthcare? Military Service: On a separate sheet of paper please explain the circumstances of any less than honorable discharge received. A less than honorable discharge will not be an automatic bar to placement on Rhino Medical Services roster of eligible Providers. MILITARY SERVICE Are you Vet-Pro Approved? Have you served in the military? Branch s of Service
7 Release and Authorization (Please read carefully) By my signature below, I authorize Rhino Medical Services to conduct background and reference checks on me regarding any information related to possible placement as a healthcare provider. This includes information on my education, licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance eligibility, and criminal history. Rhino Medical Services may gather the information from various sources including, but not limited to, consumer reporting agencies, hospitals, medical institutions or organizations, personal references, physicians, employers (past and present), business and professional associates (past and present), governmental agencies and instrumentalities (local, state, federal, or foreign), university transcript offices, medical schools, and the Office of the Inspector General. I authorize Rhino Medical Services to confirm information contained on any document that I provide Rhino Medical Services, including my curriculum vitae. I consent to Rhino Medical Services sharing this information with Rhino Medical Services clients and affiliates. I understand that upon my request, Rhino Medical Services will disclose the nature and scope of information contained in my file in accordance with federal law. A request for disclosure of information in my file must be made in writing and directed to my recruiting consultant. I authorize the above-named entities and individuals to release to state licensing boards, hospitals, and Rhino Medical Services, any information (written or oral), including medical information, files or records about me in their possession required for evaluation of my qualifications for placement as a locum tenens provider. I hereby release the above-named individuals and entities, including Rhino Medical Services, from all liability for the release of information to any state licensing board, hospital, or its agents. I further authorize Rhino Medical Services, its agents, and affiliates to release this information, including medical information, to federal, state, county, or local government entities, hospitals or other healthcare facilities, insurance providers, or any other person upon showing that the release of information is vital to the general public s health, safety and welfare. I make this release for the purpose of allowing Rhino Medical Services to assist in my request for a license to practice in my specialty and/or to assist in my efforts to work as a healthcare provider for Rhino Medical Services clients. Printed Name Signature
8 Authorization Agreement for Direct Deposit Use this form to add, change or cancel a direct deposit. All changes must be in writing and accounts must be canceled through payroll to be valid. To set up direct deposit, please take the following actions: Attach a voided check from the account. (Deposit slips are not accepted) Have the account currently set up at your bank. Verify that your bank accepts direct deposits. Verify your bank s routing number and your account number. tify the bank that you are setting up direct deposit. Verify if they have any special requirements. Account Information: New Direct Deposit Change Direct Deposit Cancel Direct Deposit Bank Name: Bank Routing # Bank Account # Authorization given by: Name (printed) Signature
9 Form W-9 Request for Taxpayer (Rev. January 2003) Identification Number and Certification Department of the Treasury Internal Revenue Service Print or type See Specific Instructions on page 2. Name Business name, if different from above Check appropriate box: Address (number, street, and apt. or suite no.) City, state, and ZIP code List account number(s) here (optional) Give form to the requester. Do not send to the IRS. Individual/ Exempt from backup Sole proprietor Corporation Partnership Other withholding Requester s name and address (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Social security number or Employer identification number Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 4.) Sign Here Signature of U.S. person Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. Note: If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Cat. No X Form W-9 (Rev )
NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security #
Page 1 NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION Last Name First Middle Place of Birth Social Security # Home Address City State Zip Office Address City State Zip DOB Emergency
More informationNASI 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 informationIndependent Contractor Information CRNA
Dear Provider: Thank you for your interest in Locum Leaders, your premier locum tenens agency. Locum Leaders provides A++ rated occurrence malpractice insurance through Med Pro. Please complete this entire
More informationCRNA APPLICATION/CHECKLIST INSTRUCTIONS:
MAXIM is an equal opportunity Employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin,
More informationAnesthesia Staffing Solutions. CRNA Application
Anesthesia Staffing Solutions CRNA Application Name of Applicant: Address: City/State/Zip: Telephone: Home: Work: Cell: E- mail: Date of Birth: Country/State of Birth Social Security Number: Driver s License
More informationThe Surgeons Company Surgeon Application
The Surgeons Company Surgeon Application Provider Name: Specialty: Date: Application Checklist for Physicians In order for us to start the process of searching for and matching you with practice opportunities,
More informationPHYSICIAN APPLICATION FOR EMPLOYMENT
PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Email Address Specialty/Sub-specialty
More informationApplication for Medical Staff Appointment and Clinical Privileges. Part I. Credential Review
Application for Medical Staff Appointment and Clinical Privileges Part I. Credential Review I am applying for clinical privileges at the location(s) checked below: 6209 16 th Avenue, Brooklyn, NY 11214
More informationInitial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)
Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at
More informationONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION
ONE CALL MEDICAL INC. NEURODIAGNOSTIC PHYSICIAN APPLICATION Provider has the right to review information submitted to support credentialing, correct erroneous information, to be informed of application
More informationSurgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates
Allied Health Staff Application Instructions We are pleased to provide you with our Allied Health Staff application packet. Please do not write see attached or see resume or CV on the application. All
More informationFederated National Underwriters Phone: (800) 293-2532 (option 4) 14050 N.W. 14 th Street, Suite 180 Fax: (954) 308-1397
AGENCY QUESTIONNAIRE Thank you for your interest in Federated National Underwriters representing Federated National Insurance Company and other nationally recognized insurance companies. Please complete
More informationCRNA INITIAL CREDENTIALING APPLICATION
CRNA INITIAL CREDENTIALING APPLICATION Revised 04/26 GENERAL INSTRUCTIONS Jackson CVO must credential all providers prior to placement into any practice location. All information requested in this application
More informationCONTRACTING INSTRUCTIONS
Adams-Moore, LLC 1441 Heather Lane Charlotte, NC 28209 Phone 704-522-9228 Fax 704-522-9118 www.adams-moore.com CONTRACTING INSTRUCTIONS NOTE: If commissions will not be paid to you individually please
More informationAPPLICATION FOR ALLIED PROFESSIONAL STAFF
Office of Medical Affairs 736 Irving Ave Syracuse NY 13210 Phone: 315-470-7646 APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal
More informationWORK PREFERENCES FORM CRNA INFORMATION PACKET SCOPE OF CLINICAL PRIVILEGES FORM PROFESSIONAL
**ALL areas must be legible and accurate. Providing complete addresses, current phone and fax numbers, and appropriate contact individuals will help expedite the credentialing process and therefore your
More informationAllied Healthcare Professional (AHP) Professional Liability Application
Allied Healthcare Professional (AHP) Professional Liability Application Coverys RRG, Inc. Agency Name NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject
More informationLast Name First Middle
P.O. Box 327 Seattle, WA 98111-0327 DENTAL PROVIDER CREDENTIALING APPLICATION This application is not a contract. The information provided in this application is used to determine whether a practitioner
More informationLos Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children
Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children This application is exclusively for prescribing practitioners
More informationNew Jersey Physician Recredentialing Application (Please type or print)
New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1 Personal Information
More informationDental Provider Practice Application
and subsidiaries Dental 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 Complete
More informationARKANSAS BOARD OF PODIATRIC MEDICINE
ARKANSAS BOARD OF PODIATRIC MEDICINE APPLICATION FOR LICENSE TO PRACTICE PODIATRIC MEDICINE 1. Name: Social Security Number: (As to appear on License) 2. Address: 3. Address you wish License to be mailed:
More informationNorth Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner
orth Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner ote: Please send completed applications directly to the organizations with which you seek to contract.
More informationHENDRICK MEDICAL CENTER INITIAL APPOINTMENT ADDENDUM
Attachment H HENDRICK MEDICAL CENTER INITIAL APPOINTMENT ADDENDUM TO THE TEXAS DEPARTMENT OF INSURANCE (TDI) STANDARDIZED CREDENTIALING APPLICATION SECTION ONE - PERSONAL INFORMATION Last Name: First Name:
More informationPRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant
PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant Prior to submitting this application it is required that you contact the Provider
More informationIndependent Contractor Application for NP/PA
Personal Information First Name Last Name Middle Name Suffix Home Phone Work Phone Cell Phone Email Address Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country) SSN Are you legally able to
More informationDental Provider Application
Dental Provider Application DENTAL APPLICATION I am applying to participate in the following EmblemHealth dental network(s): Preferred Preferred Plus Please use the checklist below to ensure we have all
More informationCREDENTIALING APPLICATION EASY AS 1, 2, 3!!!
CREDENTIALING APPLICATION EASY AS 1, 2, 3!!! 1. Complete the simple application, including consent form: sign and date. (DDN does NOT accept STAMPED signatures) 2. Make copies of the supporting documents
More informationRequest for Taxpayer Identification Number and Certification
GEORGIA REGENTS UNIVERSITY OFFICE OF STUDENT & MULTICULTURAL AFFAIRS MEDICAL COLLEGE of GEORIGA GB 3300 SUPPLEMENTAL INSTRUCTION PROGRAM SIP LEADERS SIGN-UP FORM Instructions: Please complete and have
More informationA. Clearly print or type information in each block. Complete each section entirely, indicate NOT APPLICABLE (N/A) where necessary.
Provider Application For use by Physicians and Independent Health Care Professionals BCBSF Provider Number: HCFA UPIN #: NPI #: PURPOSE: This Provider Application will be used for assigning a provider
More informationOhio 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 informationCALIFORNIA PRODUCER APPOINTMENT PACKAGE
CALIFORNIA PRODUCER APPOINTMENT PACKAGE Please complete the attached application in its entirety and submit it Multi-State Insurance Services, Inc. via one of the options listed below: Mail: E-Mail: Multi-State
More informationHow To Get A Bond In The United States
Surety 3 General Agency 625-2 Cassat Ave. Phone: 904-422-97971 Jacksonville, Fla. 32205 Fax: 901-355-5516 APPLICATION FOR NON-LIABLE SUB-AGENT APPOINTMENT You must answer every question on the Application.
More informationTo 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 informationLOCUM TENENS APPLICATION Page 1 of 4
Page 1 of 4 This form is only valid for Locum Tenens providing coverage for up to 60 days. SECTION I PROVIDER INFORMATION This section to be completed by the PacificSource participating practitioner. Please
More informationDoctors Hospital Allied Health Professional Application for Appointment
Doctors Hospital Allied Health Professional Application for Appointment Applying for the following job (please check): Allied Health Delineation of Privileges Allied Health Scope of Practice Category 1
More informationALLIANCE FOR SMILES INTERNATIONAL, INC. Application for Medical Volunteer
ALLIANCE FOR SMILES INTERNATIONAL, INC. Application for Medical Volunteer The following documents must be included with this application: Plastic Surgeon Anesthesiologist CRNA Pediatrician Dentist Dental
More informationREHAB PROVIDER NETWORK Professional Staff Credentialing Form
REHAB PROVIDER NETWORK Professional Staff Credentialing Form ***** THERAPIST LICENSE MUST BE ATTACHED TO THIS FORM ***** The information requested on this form is required to certify your status as a licensed
More informationCREDENTIALING PROFILE
CREDENTIALING PROFILE Please type or print all of the information requested on this Profile. Incomplete profiles cannot be accepted and will be returned for completion. Faxed and photocopies of this form
More informationSouthwest Michigan Behavioral Health
Southwest Michigan Behavioral Health Southwest Michigan Behavioral Health is an affiliation of Barry County Community Mental Health Authority, Kalamazoo Community Mental Health & Substance Abuse Services,
More informationContract Checklist for Mutual of Omaha Insurance Company
Contract Checklist for Mutual of Omaha Insurance Company 1. Background Information Sheet 2. Fair Credit Reporting Act Disclosure 3. General Agent Agreement/W-9 4. Direct Deposit Authorization 5. Voided
More informationDental Initial Credentialing Application
Dental Initial Credentialing Application Practitioner and Practice Information Name(last) (First) (Middle) Degree Social Security Number Personal NPI Date of Birth Gender Practice Name Practice Taxpayer
More informationMedical Assistant-Phlebotomist Certification Application Packet
Medical Assistant-Phlebotomist Certification Application Packet Contents: 1. 651-007...Contents List/SSN Information/Mailing Information...1 page 2. 651-008...Application Instructions Checklist... 2 pages
More informationLIBERTY DENTAL PLAN Provider Credentialing Application
(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 informationState of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Retired Volunteer Health Care Practitioner APPLICANT
More informationCertified Registered Nurse Anesthesis
Certified Registered urse Anesthesis (CRA) Welcome Thank you for applying to ash Health Care, Inc. Attached please find a copy of our application for you to complete. Please review the instructions and
More informationRehab Net of Arkansas. Provider Application
Rehab Net of Arkansas Provider Application Discipline P.T. O.T. S.L.P. (1) Business Name Physical Address FACILITY DATA Phone Fax (2) Billing Address Phone Fax (3) Mailing Address (4) Owner/Contact Person
More informationCHECKLIST. SIS Insurance Services 3250 Grey Hawk Ct. Carlsbad, CA 92010
Dear Producer: SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) looks forward to doing business with your agency and beginning a good working relationship. CHECKLIST Legible
More informationState of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Psychologist APPLICANT INFORMATION Full Legal
More informationNorth Carolina Delta Dental s Recredentialing Application
Delta Dental of North Carolina North Carolina Delta Dental s Recredentialing Application INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH WILL DELAY THE RECREDENTIALING PROCESS 1. The attached Recredentialing
More informationENCLOSED IS THE FORM NECESSARY FOR SUBSTITUTE PHYSICIAN (LOCUM TENENS) COVERAGE
ENCLOSED IS THE FORM NECESSARY FOR SUBSTITUTE PHYSICIAN (LOCUM TENENS) COVERAGE You must be a licensed physician in Texas. Complete and sign the Application for Coverage. Complete the Claim/Suit Information
More informationCONTRACTOR APPLICATION HOUSING REHABILITATION PROGRAM
CITY OF GALVESTON GRANTS & HOUSING DEPARTMENT P.O. Box 779 Galveston, Texas 77553 Office (409) 797 3820 Fax (409) 797 3888 CONTRACTOR APPLICATION HOUSING REHABILITATION PROGRAM CONTRACTOR APPLICATION HOUSING
More informationIRS FORM 1099 REPORTING REQUIREMENTS
IRS FORM 1099 REPORTING REQUIREMENTS The Internal Revenue Service (IRS) requires businesses (including not-for-profit organizations) to issue a Form 1099 to any individual or unincorporated business paid
More informationAPPLICATION FOR LICENSURE AS A CLINICAL ADDICTION COUNSELOR (LCAC) State Form 54089 (R3 / 1-13) Approved by State Board of Accounts, 2013 BEHAVIORAL HEALTH AND HUMAN SERVICES LICENSING BOARD PROFESSIONAL
More informationNursing Educational Loan Checklist (for individuals not currently employed by Wellmont)
Nursing Educational Loan Checklist (for individuals not currently employed by Wellmont) What is included in this packet? Guidelines and loan application form Two faculty reference forms W-9 form Wellmont
More informationVendor Registration 6103 W. Montrose Avenue, Chicago, IL 60634 p: 773.647.1992 f: 773.751.5057 www.evaluationzone.com
Vendor Registration Thank you for your interest in becoming an approved appraisal provider for evaluation ZONE, Inc. (eval). For your review, we have attached our standard appraiser approval package, which
More informationApplicants will be notified within 15 working days of receipt of a completed application as to the status of the application.
2/09, 03/11, 11/11, 01/13, 01/15 Page 1 of 10 MONTANA BOARD OF RADIOLOGIC TECHLOGISTS 301 SOUTH PARK, 4TH FLOOR PO BOX 200513 HELENA, MONTANA 59620-0513 (406) 841-2202 FAX: (406) 841-2305 email: dlibsdrts@mt.gov
More informationDental Provider Application
Dental Provider Application Dental Application Instructions To apply for participation, please fill out the enclosed application, completing all appropriate sections and providing all required materials.
More informationState of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Temporary Physical Therapist Temporary Physical Therapist Assistant APPLICANT INFORMATION Full Legal
More informationPhysician Assistant Application for Professional Liability Insurance Additional Insured Basis*
Physician Assistant Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only
More informationMedical Assistant-Hemodialysis Technician Certification Application Packet
Medical Assistant-Hemodialysis Technician Certification Application Packet Contents: 1. 651-011...Contents List/SSN Information/Mailing Information...1 page 2. 651-012...Application Instructions Checklist...2
More informationState of Utah Department of Commerce Division of Occupational and Professional Licensing
State of Utah Department of Commerce Official Use Only Number: Date Approved/Denied: Approved/Denied By: Certified Nurse Midwife APPLICANT INFORMATION Full Legal Name: First Middle Last All Previous Legal
More informationEMPLOYMENT/CREDENTIALING APPLICATION
Beacon Specialized Living Services, Inc. EMPLOYMENT/CREDENTIALING APPLICATION We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is our intention
More informationAPPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE NOTICE: The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space
More informationX-Ray Technician Limited Scope Registration Application Packet
X-Ray Technician Limited Scope Registration Application Packet Contents: 1. 686-046... Contents List/SSN Information/Mailing Information... 1 page 2. 686-027... Application Instructions Checklist...2 pages
More informationPEACE CORPS MEDICAL OFFICER APPLICATION FORM. SSN Date of birth Place of birth
PEACE CORPS MEDICAL OFFICER APPLICATION FORM Name SSN Date of birth Place of birth Citizenship Address E-mail address Telephone: (Day) (Evening) Available date Passport Information: Passport Issuing Country
More informationAPPLICATION FOR LICENSURE AS A CLINICAL SOCIAL WORKER (LCSW) State Form 50325 (R2 / 2-06) Approved by State Board of Accounts, 2006 SOCIAL WORKER, MARRIAGE AND FAMILY THERAPIST AND MENTAL HEALTH COUNSELOR
More informationPlease 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 informationDear Applicant: Sincerely, Kelli Dalrymple, Coordinator Medical and Specialized Health. Licensure Unit
Please Reply To: Licensure Unit P.O. Box 94986, Lincoln, NE 68509-4986 Phone (402) 471-2118 FAX (402) 471-3577 Dear Applicant: Thank you for your interest in becoming licensed to practice your profession
More informationANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312
ANCILLARY PROVIDER APPLICATION FOR PARTICIPATION PHYSICIANS HEALTH PLAN PO Box 30377, Lansing, MI 48909-7877 517.364.8312 INSTRUCTIONS: Please provide answers to all questions. If the answer is none, or
More informationAPPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY
Minnesota Board of Marriage and Family Therapy 2829 University Avenue SE, Suite 400 Minneapolis, MN 55414-3222 Telephone: (612) 617-2220 Fax: (612) 617-2221 Email: mft.board@state.mn.us Website: www.bmft.state.mn.us
More informationNEIGHBORHOOD HEALTH PLAN OFRHODE ISLAND CREDENTIALING PRACTITIONER APPLICATION
NEIGHBORHOOD HEALTH PLAN OFRHODE ISLAND CREDENTIALING PRACTITIONER APPLICATION Neighborhood accepts the Council for Affordable Quality Healthcare (CAQH) application in lieu of Neighborhood s standard credentialing
More informationRockbridge Underwriting Agency Limited 3700 Buffalo Speedway, Suite 300 Houston, TX 77098 (713) 874-8800 (713) 874-8899 fax
Rockbridge Underwriting Agency Limited 3700 Buffalo Speedway, Suite 300 Houston, TX 77098 (713) 874-8800 (713) 874-8899 fax Corporate Locum Tenens Underwriting Questionnaire and Application for Professional
More informationPHYSICIAN EXTENDER APPLICATION
An Independent Licensee of the Blue Cross and Blue Shield Association PHYSICIAN EXTENDER APPLICATION Instructions: Please PRINT or TYPE a response for each question. Please attach the copies of the documents
More informationMASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN 55447 763-509-5000
MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN 55447 763-509-5000 The following application forms must be completed, by the individual
More informationNow Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012
Now Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012 The University of California Los Angeles School of Nursing Health Center at the Union Rescue
More informationSTREET ADDRESS: 3250 GREY HAWK CT., CARLSBAD, CA 92010 PHONE: 760-599-7242 *FAX:
Dear Producer: SafeBuilt Insurance Services, Inc. (SIS), DBA: Structural Insurance Services (SIS) looks forward to doing business with your agency and beginning a good working relationship. CHECKLIST Legible
More informationHypnotherapist Registration Application Packet
Hypnotherapist Registration Application Packet Contents: 1. 670-088...Contents List/SSN Information/Mailing Information...1 page 2. 670-053...Application Instruction Checklist... 2 pages 3. 670-052...Hypnotherapy
More informationTECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION
Page 1 of 8 MONTANA BOARD OF PHARMACY (301 S PARK, 4 TH FLOOR, HELENA, MT 59601 - Delivery) P. O. Box 200513 Helena, Montana 59620-0513 PHONE (406) 841-2300 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov
More informationNurse Practitioner Application for Professional Liability Insurance Additional Insured Basis*
Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only
More informationProfessional Liability Insurance Application Claims Made Basis. Short Form
Preferred Professional Insurance Company Professional Liability Insurance Application Claims Made Basis Short Form IMPORTANT INSTRUCTIONS - PLEASE READ CAREFULLY 1. PLEASE MAKE SURE ALL QUESTIONS ARE ANSWERED
More informationHow To Apply To The Nursing Program At The University Of South Dakota
RN-BSN IN NURSING APPLICATION PROCEDURE Admission to The University of South Dakota Nursing Program is a two-step process. The following checklist will assist you in this process. All items must be completed
More informationMissouri Lottery Winner Claim Form Official Missouri Lottery Claim Form
[ STAPLE TICKET HERE ] Missouri Lottery Winner Claim Form Official Missouri Lottery Claim Form A B C PLEASE PRINT your name, address and phone number on the back of your ticket - YOU MUST SIGN YOUR TICKET.
More informationMARYLAND HOSPITAL CREDENTIALING APPLICATION
Error! STATE OF MARYLAND DHMH MARYLAND HOSPITAL CREDENTIALING APPLICATION Please type or print. Incomplete or illegible applications will not be processed. I. PERSONAL INFORMATION Name (Last, First, Middle)
More informationResident Credentialing Policy Wayne State University
Resident Credentialing Policy Wayne State University REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENT Residency Office Responsibilities: 1. Resident Initial Appointment Recommendation Letter: Initial applications
More informationFinancial Forms for U.S. Based Institutions
ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 1 Financial Forms for U.S. Based Institutions Your institution must submit completed financial forms in order
More informationCommunity Health Group Allied Health Professional Application
Community Health Group Allied Health Professional Application Nurse Practitioner Certified Nurse Midwife LCSW Clinical Psychologist MFCC Other I. INSTRUCTIONS This form should be typed or legibly printed
More informationSocial Worker Associate Advanced or Social Worker Associate Independent Clinical License Application Packet
Social Worker Associate Advanced or Social Worker Associate Independent Clinical License Application Packet Contents: 1. 670-105...Contents List/SSN Information/Mailing Information...1 page 2. 670-106...Application
More informationFOR INTERNAL USE ONLY: LT_APP ID: PHYSICIAN: RECRUITER: SPECIALTY: SIGN OFF:
FOR INTERNAL USE ONLY: LT_APP ID: PHYSICIAN: RECRUITER: SPECIALTY: SIGN OFF: As part of our commitment to quality, Medical Doctor Associates requires that Independent Contractors periodically undergo a
More informationState of Tennessee Department of Health BOARD OF VETERINARY MEDICAL EXAMINERS
State of Tennessee Department of Health BOARD OF VETERINARY MEDICAL EXAMINERS 665 Mainstream Drive Nashville TN 37243 (Toll Free Instate) 1-800-778-4123 Ext. 5325090 615-532-5090 tn.gov/health Procedures
More informationOCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST
STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement:
More informationMOONLIGHTING INSTRUCTIONS:
MOONLIGHTING INSTRUCTIONS: Please Complete and Send the Forms on the Following 6 Pages to the Medical Staff Office at Box URMFG 278911. 1) URMC Moonlighting (extra work shift) Request Form, p. 1 of 6 2)
More informationAPPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE NOTICE: The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space
More informationBENEFICIARY STATEMENT INSTRUCTIONS
Farm Bureau Life Insurance Company 5400 University Avenue West Des Moines, Iowa 50266-5997 800-247-4170 / FAX: 1-800-814-5561 BENEFICIARY STATEMENT INSTRUCTIONS INSTRUCTIONS FOR COMPLETION OF BENEFICIARY
More informationLicensure by Examination Information For Graduates from Nursing programs within the United States
17938 SW Upper Boones Ferry Road Portland, Oregon 97224-7012 Licensure by Examination Information For Graduates from Nursing programs within the United States Non-United States Graduate: If you studied
More informationCredentialing and Contracting Instructions
Credentialing and Contracting Instructions What s required? All Dentists who want to enroll with DentaQuest must be credentialed AND contracted before you can begin treating members. To get credentialed
More information5Star Life Insurance Company Agent & Agency Contracting Packet
5Star Life Insurance Company Agent & Agency Contracting Packet (Includes) Agent & Agency Data Sheet Anti-Money Laundering Training Certification Ethical Selling Guide/Guide for Doing Business with 5Star
More informationAll Physicians must attend orientation. Your office will be contacted to schedule a time convenient for you.
Dear Doctor: Thank you for your interest in applying for Medical Staff Membership and or Clinical Privileges at Northwest Texas Healthcare System/Northwest Texas Surgery Center and or Alliance Regional
More informationMASSACHUSETTS STATE LOTTERY COMMISSION
MASSACHUSETTS STATE LOTTERY COMMISSION LICENSE APPLICATION BOOKLET Supporting the 351 Cities and Towns of Massachusetts Timothy P. Cahill Treasurer and Receiver General 1 Mark J. Cavanagh Executive Director
More informationMASSACHUSETTS STATE LOTTERY COMMISSION LICENSE APPLICATION BOOKLET
MASSACHUSETTS STATE LOTTERY COMMISSION LICENSE APPLICATION BOOKLET Supporting the 351 Cities and Towns of Massachusetts Deborah B. Goldberg Treasurer and Receiver General 1 Michael R. Sweeney Executive
More information