Health Partners Recredentialing Application

Transcription

1 Health Partners Recredentialing Application Thank you for your interest in a Health Partners membership. Please note: All fields require a response. For all text fields that are not applicable, type N/A. For all dates that are not applicable, enter today s date. Any gaps in education, work history, or insurance coverage must include an explanation. ALL providers must download the Consent to Release document here, sign it, and fax it to This document must be received before Health Partners can begin the credentialing process. Download a copy of the CCVS Attestation and Authorization & Release forms here. Once completed, fax both forms and a current Curriculum Vitae (CV) to (479) Please have all records related to education, board certification, licensures, work history, and malpractice insurance readily available, as the application must be completed in its entirety to be submitted. Currently, there is not an option to save progress. Please print screen a copy for your records. For questions or assistance with this application, please call Provider Information First Name* Last Name* Primary Degree* Secondary Degree* Expertise/Practicing Specialty* Gender* Date of Birth * SS Number* * Has the provider used any other names?* If so, please indicate Date of Name Change* NPI Number* CAQH Number* License Information License Number* Issuing State*

2 Status* Issue Date* Does the provider have licenses in other states?* If yes, please list ("N/A" if not applicable)* Board Certification Primary Specialty* Board Certified* Issuing Date* Secondary Specialty* Board Certified* Issuing Date* Does the provider have any additional Board certifications?* Has the provider experienced any board actions or sanctions?* Please explain ("N/A" if not applicable)* DEA License Does the provider have a DEA license?* DEA Number ("N/A" if not applicable)* Expiration Date (enter today's date if not applicable)*

3 Malpractice Insurance Information Does the provider have current medical liability insurance coverage?* Carrier* Policy Number* Issue Date* Coverage Amount (Occurence)* Coverage Amount (Aggregate)* Did this carrier pay out any claims for this provider? * NA Has the provider had additional insurance policies during time of practice?* Has the provider had any gap in insurance coverage?* Please explain ("N/A" if not applicable)* Provider History Has the provider had any settled malpractice claims?* Has the provider had any dismissed malpractice claims?* Does the provider have notice of intent or pending settlement malpractice claims?* Have any of the following been, or are currently in the process of being, investigated, reduced, limited, placed on probation, not renewed, voluntarily relinquished, revoked, canceled, denied, or granted with stated limitations (temporarily or permanently) Medical license in any state* Other professional registration* Academic appointment*

4 Membership on any hospital or other medical staff* Participation in any federal or state health program* Participation in any private health program* Professional organization membership* DEA registration* Board certification* Clinical privileges* Have you ever had a felony or misdemeanor conviction, other than minor traffic violations?* Is there any reason that you are not able to perform your essential functions of your position, with or without accommodations?* Are you currently engaged in the unlawful use of drugs?* Have any quality of care concerns been identified?* Hospital Privileges Please explain any questions answered yes ( N/A, if not applicable)* Does the provider have privileges with Washington Regional Medical Center?* If yes, what type of privileges ( N/A, if not applicable)?* If yes, provide initial appointment date (enter today's date if not applicable) Does the provider have admission privileges?* Does the provider have privileges with other hospitals?*

5 If yes, please list ( N/A, if not applicable)* Do you care for patients under 18?* HWork History (minimum five years) Employer #1 Employer #2 Employer #3 Employer #4

6 Employer #5 Does the provider have additional work history in the last five years?* Has the provider had any gap in work history?* Data Collector Information Please explain ( N/A, if not applicable)* Comments/Additional Information* Name of Person Completing Application* Preferred contact s address* Today's Date* Please remember to download the CCVS and A&R forms, sign, and return to Health Partners! Clinic Name* SUBMIT CANCEL