nh uniform application for hospital credentialing

NH UNIFORM APPLICATION

FOR

HOSPITAL CREDENTIALING

©1999 New Hampshire Association Medical Staff Services Duplication by any manner whether in whole or in part is prohibited without the express written permission

of the New Hampshire Association Medical Staff Services.

Please print or type.

Applicant Name

Healthcare Facility Date Original Sent

INSTRUCTIONS

The process below will save you time and duplication of effort if utilized properly.

If you have NOT completed this application previously, please proceed with the application in its entirety and keep a copy for your files. OR If you have already applied for medical staff appointment and/or clinical privileges at a New Hampshire healthcare facility and completed the uniform application at that facility, please proceed with the following steps: 1. Photocopy the cover page and pages 1 - 8 of the NH Uniform Application for Hospital

Credentialing you had completed for the original facility. You do not need to complete this information again, but update as needed by drawing a line through the outdated information and legibly printing the modification. All changes must be initialed and dated. Do not use white-out. Photocopies must be legible.

2. Complete the originals of pages 9 - 15. 3. Review, sign, date and return the application with any addendum page(s), including any forms

specific to the facility you are applying to. These may include privilege request forms and release authorizations.

Not all information requested may apply to you. If the requested information does not apply, please indicating by typing or writing N/A in the space provided.

PLEASE DO NOT LEAVE BLANKS

If you have questions, call the healthcare facility to which you are applying.

Uniform Application for Credentialing Copyright 1995 NHAMSS

I. PERSONAL IDENTIFICATION DATA (Please Type or Print Legibly)

Full Legal Name:

Last Suffix First Middle Degree

Other Names Used (e.g., Maiden, Married) Please also indicate date range of other names used.

From To

From To

MM/YYYY MM/YYYY

Male Female DOB SSN NPI Number

MM/DD/YYYY

Are you a US citizen? Yes No Birthplace

City/State Country

If not a US citizen, give status and VISA number Status: VISA #:

Foreign Languages Spoken: II. HOME ADDRESS Street: Phone: Cell Phone:

City/State/Zip: E-Mail:

Mailing Address (if different from above):

City/State/Zip: III. PRIMARY OFFICE/ANTICIPATED OFFICE LOCATION Practice/Corporation Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:

Type of Practice: Solo: Group: Clinic: Other:

Administrative Contact Person:

Names of Associates in Practice:

IV. OTHER OFFICE LOCATIONS

Practice/Corporation Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:




Practice/Corporation Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:




Page 1

Name:

V. COVERING PROVIDERS – List those providers that cover for you in your absence.

Name:

Practice Name:

Address: Suite:

City/State/Zip:

Phone: Fax: Name:

Practice Name:

Address: Suite:

City/State/Zip:

Phone: Fax:

VI. PROFESSIONAL EDUCATION EXPERIENCE

Undergraduate School:

Address: Suite:

City/State/Zip:

Phone: Fax: From: To: Degree: MM/DD/YYYY MM/DD/YYYY Medical or Professional School:

Address: Suite:

City/State/Zip:

Phone: Fax: From: To: Degree: MM/DD/YYYY MM/DD/YYYY

Program Completed: Yes No International Medical Graduate: Yes No ECFMG No: Year Issued:

Internships and Residencies: List all programs ever begun. If not completed, give reason on a separate sheet of paper.

Type: Internship Residency

Institution:

Address: Suite:

City/State/Zip:

Phone: Fax: From: To: MM/DD/YYYY MM/DD/YYYY

Program Completed: Yes No Program Director:



Institution:

Address: Suite:

City/State/Zip:



Page 2

Name:

VI. PROFESSIONAL EDUCATION EXPERIENCE – Continued



Institution:

Address: Suite:

City/State/Zip:


Program Completed: Yes No Program Director: Fellowships and Postgraduate Training: List all programs ever begun. If not completed, give reason on a separate sheet

of paper. Type:

Institution:

Address: Suite:

City/State/Zip:


Program Completed: Yes No Program Director: Fellowships and Postgraduate Training: List all programs ever begun. If not completed, give reason on a separate sheet

of paper. Type:

Institution:

Address: Suite:

City/State/Zip:



List any additional education experience on a separate sheet of paper.

VII. SPECIALTIES PRACTICED/BOARD CERTIFICATIONS/OTHER ORGANIZATIONS – Attached copies of

certificates Specialty: Certified: Yes No

Name of Certifying Organization:

Certification Date: Expiration Date: Recertification Date:

Are you participating in Maintenance of Certification (MOC)? N/A Yes No

Sub-Specialty: Certified: Yes No

Name of Certifying Organization:

Certification Date: Expiration Date: Recertification Date: MM/DD/YYY MM/DD/YYY MM/DD/YYYY

Are you participating in Maintenance of Certification (MOC)? N/A Yes No

If not certified, have you taken and not passed a certification exam? Yes No

If not certified, are you actively involved in the certifying process? Yes* No

*If Yes, please document status in process (e.g. letter of acceptance to sit for exam):

Scheduled date of exam: In what specialty

Page 3

Name: VIII. INSTITUTIONAL AFFILIATION/WORK HISTORY – List, in chronological order, all professional employment and

appointments, past and present, to include hospitals, institutional affiliations, medical office practices, clinical employment, locum tenens, etc. Staff categories may include Active, Courtesy, Consulting, etc. List additional professional experiences and affiliations on a copied form or on a separate sheet, providing complete information as requested below.

Current Institution:

Address: Suite:

City/State/Zip:

Phone: Fax: Staff Category: Dept:

Does this include admitting privileges? Yes No

If you do not have admitting privileges, please provide a detailed description of what your arrangements are for hospital admission and inpatient coverage of your patients.

Dates of Appointment: From: To: If no longer affiliated, give reason: MM/DD/YYYY MM/DD/YYYY

Department Chair/Direct Clinical Supervisor Name:

Phone: Fax: E-Mail:

Other Institution:

Address: Suite:

City/State/Zip:






Phone: Fax: E-Mail:

Other Institution:

Address: Suite:

City/State/Zip:






Phone: Fax: E-Mail:

Page 4

Name:

Other Institution:

Address: Suite:

City/State/Zip:






Phone: Fax: E-Mail:

Other Institution:

Address: Suite:

City/State/Zip:






Phone: Fax: E-Mail:

Other Institution:

Address: Suite:

City/State/Zip:






Phone: Fax: E-Mail:

Page 5

Name:

EXPLANATION OF WORK HISTORY GAP(S): Any time periods or gaps since graduation from professional school of greater than 1 month which are not explained in the application thus far, must be addressed here. If the application is found to have any unexplained time periods or gaps, the application may not be processed and may be returned to the applicant as incomplete. Please explain any such gaps in the space provided below.

From MM/YYYY

To MM/YYYY Explanation of Work History Gap

Page 6

Name:

IX. LICENSE INFORMATION – List all current and past professional license(s) held, i.e., MD, DO, APRN, PA, etc. and

any training licenses such as residency, fellowship, etc. Attach a copy of all of your current licenses.

License Number

License Type

State

Date Issued

Expiration Date

Status

Active Inactive MM/DD/YYYY MM/DD/YYYY






Active Inactive MM/DD/YYYY MM/DD/YYYY X. FEDERAL DEA AND CONTROLLED SUBSTANCE REGISTRATION – If applicable, list all Federal DEA

Registration(s) held. Attach a copy of your current Federal DEA Registration(s).

Federal DEA # Issue Date Expiration Date

MM/DD/YYYY MM/DD/YYYY




If applicable, list all state controlled substance certificate number(s). Please attach a copy of your current state certificate(s).

State Certificate # Issue Date Expiration Date





XI. CURRICULUM VITAE – Please attach a current curriculum vitae which includes a complete description of professional

experience, work history including all hospital and practice locations with start and end dates in a MM/YYYY format, awards or honors, lectures and/or seminars, articles written and published, memberships and/or societies, etc. Include an explanation of any gaps of time in your chronology.

Page 7

Name:

XII. REFERENCES – List three (3) peer references that have current and first-hand knowledge of your clinical capabilities,

ethical character and ability to work cooperatively with others. References will be evaluated according to the extent of their direct clinical observations and other work with you. Do NOT list current associates in practice, current partners, anyone listed previously in application or relatives, if possible. Please defer to the instructions of the institution to which you are applying.

Name: Title: Salutation:

(MD, DO, APRN) Dr., Mr., Ms., Mrs., etc

Specialty: Relationship:

Practice Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:




Practice Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:




Practice Name:

Address: Suite:

City/State/Zip:

Phone: Fax: E-Mail:

Page 8

Name: XIII. PROFESSIONAL LIABILITY DATA – List professional liability carriers for the past 10 years. (List additional

carriers on separate sheet.)

Current Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:

Policy Number: Dates of Coverage: From: To:

Coverage Amounts Per Occurrence: $ Aggregate: $

Class of Coverage: Claims Made Occurrence

Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:




Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:




Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:




Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:




Carrier Name:

Address: Suite:

City/State/Zip:

Phone: Fax:




Page 9

Name: PROFESSIONAL LIABILITY DATA (Continued) 1. Has your professional liability insurance coverage ever been terminated by action of the

insurance company?

Yes

No

2. Have you ever been denied professional liability coverage or been rated up? Yes No 3. Has your present professional liability insurance carrier excluded any specific procedures from

your coverage? Yes No

If you answered YES to any of the above questions (1-3), please explain on a separate page.

4. Have you ever been the subject of any professional liability claims or suits? Yes No

If yes, how many?

5. Are you the subject of any professional liability claim or suit which is presently pending? Yes No

If yes, how many?

6. Have any judgments or settlements ever been made involving you in a professional liability case? Yes No

If yes, how many?

If you answered YES to any of the above questions (4-6), please complete the next page.

Signature

Date

Page 10

MALPRACTICE CLAIMS/SUIT HISTORY

PLEASE COPY THIS PAGE FOR ANY ADDITIONAL CLAIM(S) AND/OR SUIT(S)

Name of Claimant: Carrier at time of incident:

Date of Alleged Incident: Date Lawsuit Filed:

Name of Court and Case Number:

Please provide a summary adequate to describe the clinical significance of the claim:

Status of Case (with reference to you specifically): What was/is your status:

Notice of claim filed Sole defendant

Pending before malpractice panel Co-defendant with:

Pending in court

Closed without payment, date:

Pre-trial settlement $ date

Verdict for defendant; date: Other:

Verdict for plaintiff $ date

Name of Claimant: Carrier at time of incident:

Date of Alleged Incident: Date Lawsuit Filed:

Name of Court and Case Number:

Please provide a summary adequate to describe the clinical significance of the claim:

Status of Case (with reference to you specifically): What was/is your status:

Notice of claim filed Sole defendant

Pending before malpractice panel Co-defendant with:

Pending in court

Closed without payment, date:

Pre-trial settlement $ date

Verdict for defendant; date: Other:

Verdict for plaintiff $ date

Signature of Applicant Date

Page 11

Name:

XIV. REQUIRED INFORMATION – Please answer each of the following questions. If you answer YES to any of the

questions below, please provide explanation(s) on a separate sheet of paper. Please initial and date any changes.

1. Have there ever been any disciplinary actions or investigations initiated and/or closed or are there any pending against you by any state licensure board, healthcare facility or health plan?

Yes No

2. Have you ever withdrawn your application for appointment, reappointment or clinical privileges or resigned voluntarily before a decision was made by the governing body of any healthcare facility or health plan?

Yes No

3. Have you ever been placed on probation, disciplined, formally reprimanded, suspended or been asked to resign during a professional educational program or is any such action or challenge currently pending?

Yes No

4. Have you ever while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any professional educational program?

Yes No

5. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private insurance entity, or federal or state health insurance program (i.e., Medicare, Medicaid)?

Yes No

6. Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal or state health insurance program?

Yes No

7. Have you ever been denied membership or renewal thereof, including but not limited to having been the subject of disciplinary proceedings, reprimand or sanctions in any professional organization, healthcare facility or health plan?

Yes No

If you answer Yes to any of the questions below, please provide an explanation on the designated line,

i.e., “voluntary resignation due to relocation”, etc.

8. Have any of your professional license(s) ever been relinquished, denied, restricted, limited, surrendered, suspended, revoked or not renewed, or otherwise disciplined either voluntarily or involuntarily or is any action or challenge currently pending?

Yes No

If YES, please explain:

9. Have any of your professional certifications or registrations ever been relinquished, denied, restricted, limited, surrendered, suspended, revoked or not renewed, or otherwise disciplined either voluntarily or involuntarily or is any action or challenge currently pending?

Yes No


10. Has your federal and/or state narcotics registration certificate(s) ever been relinquished, denied, restricted, limited, suspended, surrendered, revoked or not renewed, or otherwise disciplined either voluntarily or involuntarily or is any action or challenge currently pending?

Yes No


Signature Date

Page 12

Name:

REQUIRED INFORMATION – continued. Please answer each of the following questions.

If you answer Yes to any of the questions below, please provide an explanation on the designated line,

i.e., “voluntary resignation due to relocation”, etc.

11. Has your professional staff appointment or employment at any healthcare facility or health plan ever been relinquished, denied, restricted, limited, suspended, surrendered, revoked or not renewed, either voluntarily or involuntarily or is any action or challenge currently pending?

Yes No


12. Have your clinical privileges at any healthcare facility or health plan ever been relinquished, denied, restricted, limited, suspended, surrendered, revoked or not renewed, either voluntarily or involuntarily or is any action or challenge currently pending?

Yes No

If Yes, please explain:

13. Have you been convicted of, pled guilty, pled nolo contendere or been named as a defendant in a felony or in a criminal proceeding including driving while under the influence or driving while suspended, but not including traffic offenses not classified as misdemeanors?

Yes No

If Yes, please explain:

14. Have you ever been reprimanded, suspended, granted conditional appointment, investigated, placed on probation, disciplined, fired, terminated, asked to leave or asked to resign from any of your medical office practices, professional organizations, healthcare facilities or health plans?

Yes No

If yes, please explain:

I certify that statements, answers and supporting documents were supplied by me for this application and that they are correct, complete, true and accurate to the best of my knowledge and belief. Signature

Date

Page 13

Name:

MUST SEND SIGNED ORIGINAL ONLY!

NHAMSS UNIFORM APPLICATION FOR MEDICAL STAFF CREDENTIALING

ATTESTATION FORM

Enclosed is a copy of an original application (pages 1 - 8), submitted previously to another healthcare facility or health plan in accordance with instructions enclosed with my credentialing packet. All pages and addendums subsequent to page 8 are originals. I certify that statements, answers and supporting documents were supplied by me for this application and that they are true and complete to the best of my knowledge and belief.

Any changes since comple-tion of original application

YES NO Healthcare Facility/Health Plan

Date Sent

Signature of Applicant


Date Sent



Date Sent



Date Sent


If the answer to any of the above is YES, please explain fully on a separate sheet of paper and return with the application.

Page 14

Name:

XV. HEALTH STATUS Your application will be processed in the usual manner regardless of how you answer the following questions. 1. Are you physically and mentally able to perform all the essential functions or services

necessary to exercise the privileges or services applied for with or without a reasonable accommodation?

Yes No

If NO, please explain:

2. Do you use any chemical substances that would in any way limit or impair your ability to practice medicine and perform the functions of your job with reasonable skill and safety?

Yes No


I certify that statements, answers and supporting documents were supplied by me for this application and that they are correct, complete, true and accurate to the best of my knowledge and belief. Signature Date

Page 15

Name:

ADDITIONAL EXPLANATION SHEET (IF NEEDED)

Please make reference to the question being answered

Page Section or Question Number




Signature Date

Page 16

nh uniform application for hospital credentialing

Documents