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 are acceptable. Section I. PERSONAL INFORMATION NAME First Middle Last Suffix - - / / Social Security Number Date of Birth To help us comply with the State of Tennessee Diversity Program, please check the appropriate ethnicity Male Asian Black Caucasian Female Hispanic Other Prefer not to respond Section II. OFFICE INFORMATION If you have additional offices, please include this information on a separate attachment. PRIMARY OFFICE TIN Type 2 NPI Name of Practice Street Address SECONDARY OFFICE TIN Type 2 Name of Practice Street Address City State Zip City State Zip Telephone Number ( ) Telephone Number ( ) Fax Number ( ) Fax Number ( ) Office E-mail Address Website Address Office E-mail Address Website Address Please list other licensed dentists in your practice 1
Section III. LICENSES Check appropriate box: General Practitioner Specialist in Are you currently Board certified? TN License Number Expiration Date Type 1 NPI Number (required) Federal DEA or CDS # Expiration Date Section IV. EDUCATION Dental School Attended Degree Awarded Year Graduated Section V. COMPLIANCE AND INSURANCE 1. Do you follow Center for Disease Control guidelines for Infection Control in Dental Health Care Settings and observe all applicable laws and regulations related to the practice of dentistry including, but not limited to, those dealing with infection control and employee safety in the work place? Yes No 2. Do you have current professional malpractice insurance coverage and agree to maintain continuous, uninterrupted coverage while participating in the program. Please note that under the terms of participation that you further agree to notify Delta Dental immediately of any policy cancellation, lapse in coverage, reduction in coverage maximums or claims made? 3. Do you have current liability coverage and agree to maintain continuous, uninterrupted coverage while participating in this program? Please not that under the terms of participation that you further agree to notify Delta Dental immediately of any policy cancellation, lapse in coverage, and reduction in coverage maximum or claims made? 4. Has your professional liability insurance ever been denied, suspended, revoked, cancelled, or not renewed? If yes, please explain: 2
Section VI. PROFESSIONAL INFORMATION 1. Has your license to practice in any jurisdiction, whether past or still pending, been denied, restricted, limited, suspended, revoked, not renewed, placed under probation, subjected to disciplinary action, or otherwise sanctioned, limited or curtailed? Yes No 2. Has your Federal and/or State DEA license or applicable drug license ever been denied, suspended, canceled or not renewed, or subjected to any disciplinary action? 3. Has your status as a provider ever been denied, suspended, canceled or sanctioned by any municipal, state, federal or governmental agency (e.g. Medicare, Medicaid, and OIG)? 4. Are your privileges or memberships any hospital, institution (Military service) and /or HMO currently under investigation or have the ever been denied, suspended, reduced or not renewed? 5. Have you ever been denied membership, or renewal of membership, or been subject to disciplinary proceeding for a medical, dental or ethical reason by any dental/professional organization? 6. Are you unable to perform any procedures within the scope of privileges and duties in your position as a health care provider, with to without reasonable accommodation required by the Americans With Disabilities Act, with accepted standards of professional performance and without posing a direct threat to patients? 7. Do you currently, or did you in the last five (5) years, engage in the unlawful use of illegal drugs, including improper use of prescription drugs? 8. Do you have any felony or misdemeanor charges pending against you or have you ever been convicted of a felony, or pleaded nolo contendere to a felony? 9. Have you been involved in ANY malpractice (or any civil) claims/lawsuits, settlements or judgments within the last five years? If yes, please provider detailed information on a separate sheet of paper including: docket number of the case, location of the court, names of the parties, Plaintiff(s) and defendant(s), date of the incident(s), description of the incident(s), your involvement, current disposition, and the amount of the settlement(s). 10. Have you ever been reported to the National Practitioner Data Bank? Yes No 11. Within the past five (5) years, have you ever had any substance abuse problems that would impair your ability to practice dentistry? If yes, please explain: 3
PROFESSIONAL ATTESTATION AND RELEASE Dentist First Name (please print) Middle Initial Last Name Suffix Dentist Date of Birth Dentist License Number State Issuing License I authorize the State Board (or other dental licensing agencies in any state in which I am licensed to practice dentistry) to release any information regarding my license to Delta Dental. I authorize all universities or dental schools that I have attended to release any degrees or relevant transcripts to Delta Dental. I authorize the health care facility or professional organization with who I was previously employed to release any information regarding my employment to Delta Dental. I authorize and request my insurance carrier(s) to release information regarding information to Delta Dental for the purpose of evaluating my provider participation application, credentials and qualifications. Further, I release Delta Dental for their acts performed in good faith and without malice, in connection with the evaluation of my provider participation application, credentials and qualifications. I authorize Delta Dental to consult with any other persons or entities that are necessary in order for Delta Dental to evaluate my professional qualifications including competence, ethics and other qualifications. I certify that all of the information provided is accurate and true to the best of my knowledge and agree to notify Delta Dental, in writing, of any changes in this document within 10 days of their occurrence. I understand that information which is found to be false could result in denial/termination of participation status with Delta Dental. A copy of this attestation and release is valid. Dentist Name (please print) Dentist signature Date Return this form to: Professional Relations Delta Dental of Tennessee 240 Venture Circle Nashville TN 37228 Fax: 615-742-6940 Email: cbruce@deltadentaltn.com 4
AUTHORIZATION FORM TO INSURANCE CARRIER/AGENT I hereby authorize the below named insurance carrier/agent to provide a copy of the declaration page of my current professional liability (malpractice) insurance to Delta Dental of Tennessee. The insurance carrier/agent is also instructed to provide Delta Dental with a copy of each yearly renewal of this policy and in the event of cancellation, a copy of the cancellation notice. Name of Insurance Carrier/Agent Policy Number ( ) - Telephone Number Address City State Zip Code Dentist Name (please print) Date Dentist Signature Please send all copies to: Professional Relations Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Phone (888) 281-9396 Fax (615) 742-6940 Email: cbruce@deltadentaltn.com 5