O
REGON
P
RACTITIONER
C
REDENTIALING
A
PPLICATION
APPLICATION
PROFESSIONAL
LIABILITY
ACTION
DETAIL
(ATTACHMENT
A)
GLOSSARY
OF
TERMS
AND
ACRONYMS
P
URPOSE
:
E
STABLISHED BY HOUSE BILL
2144
(1999),
THE ADVISORY COMMITTEE ON PHYSICIAN
CREDENTIALING INFORMATION
(ACPCI)
DEVELOPS THE UNIFORM APPLICATIONS USED BY
HOSPITALS AND HEALTH PLANS TO CREDENTIAL AND RECREDENTIAL
PRACTITIONERS
WITHIN THE
S
TATE OF OREGON
.
REVIEWED,
AMENDED
&
APPROVED
BY THE ADVISORY COMMITTEE ON PHYSICIAN CREDENTIALING INFORMATION (ACPCI)
5/1/12
Oregon Practitioner Credentialing Application
5/1/12
Page 1 of 12 INITIALS: ____________DATE: _____________________________
OREGON PRACTITIONER CREDENTIALING APPLICATION
Prior to completing this credentialing application, please read and observe the following:
I. INSTRUCTIONS
This form should be typed (using a different font than the form) or legibly printed in black or blue ink. If more space is
needed than provided on original, attach additional sheets and reference the question being answered.
Modification to the wording or format of the Oregon Practitioner Credentialing Application
will invalidate the application.
Complete the application in its entirety. Keep an unsigned and undated copy of the
application on file for future requests. When a request is placed, send a copy of the
completed application to the health care related organization to which you are applying,
making sure that all information is complete, current and accurate.
Please sign and date page 11, Attestation Questions and page 12, Authorization and Release
of Information Form (and Attachment A, Professional Liability Action Detail, if applicable).
Each page of the application requires the applicant’s initials and the date on which the
application was last reviewed.
Identify the health care related organization(s) to which this application is being submitted
in the space provided below.
Attach copies of the documents requested each time the application is submitted.
If a section does not apply to you, please check the provided box at the top of the section.
Mail application to the requesting organization(s).
Current copies of the following documents must be submitted with this application:
State Professional License(s)
DEA Certificate or CSR Certificate
ECFMG (if applicable)
Face Sheet of Professional Liability Policy or Certificate
A curriculum vitae is optional and not an acceptable substitute.
I am applying to (please list: Hospital Staff, HMO, IPA): __________________________
for: __________________
(i.e., staff membership, network participation, if applicable).
*Note: Please return completed application to the health care related organization to
which you are applying not to the State of Oregon.
Oregon Practitioner Credentialing Application
5/1/12
Page 2 of 12 INITIALS: ____________DATE: _____________________________
OREGON PRACTITIONER CREDENTIALING APPLICATION
II. PRACTITIONER INFORMATION
Please provide the practitioner’s full legal name.
Last Name (include suffix; Jr., Sr., III):
First:
Middle:
Degree(s):
Is there any other name under which you have been known or have used since starting professional training
?
Yes No
Home Street Address:
Home Telephone Number
( ) -
Mobile/Alternate Number
( ) -
Email Address:
City:
State:
ZIP:
Country:
Birth Date: Month / Day / Year
Birth Place:
Citizenship:
Social Security Number:
Gender:
Male Female
Immigrant Visa Number (if applicable):
Visa Expiration Date
Status:
Type:
Educational Commission for Foreign Medical Graduates (ECFMG) Number (if applicable):
Month / Year Issued:
III. SPECIALTY INFORMATION
This information may be included in directory listings.
Principal clinical specialty
(
For most c
urrent specialties list, see:
http://www.wpc-edi.com/codes):
Do you want to be designated as a primary care practitioner (PCP)?
Yes
No
Additional clinical practice specialties:
Category of professional activity, check all boxes that apply:
Clinical Practice: Other Professional Activities:
Full Time
Part Time
Administration
Teaching
Locum / Temporary
Telemedicine
Research
Retired
Other (explain)
Other (explain)
IV. BOARD CERTIFICATION / RECERTIFICATION
This section does not apply to licensure.
Does Not Apply
List all current and past certifications. Please attach additional sheets, if necessary.
Name and Address of Issuing Board Specialty
Date
Certified/Recertified
Month / Year
Expiration Date
(if any)
Month / Year
If not currently board certified, describe your intent for certification, if any, and dates of previous testing and/or intended future
testing for certification below. Please attach additional sheets, if necessary.
Oregon Practitioner Credentialing Application
5/1/12
Page 3 of 12 INITIALS: ____________DATE: _____________________________
V. OTHER CERTIFICATIONS
Please attach copy of certificate(s), if applicable
.
Examples include: ACLS, BLS, ATLS, PALS, NRP, AANA, Fluoroscopy, Radiography, etc.
Type:
Number:
Month / Year of Certification:
Month / Year of Expiration:
Type:
Number:
Month / Year of Certification:
Month / Year of Expiration:
Type:
Number:
Month / Year of Certification:
Month / Year of Expiration:
Type:
Number:
Month / Year of Certification:
Month / Year of Expiration:
For additional certifications, please attach a separate sheet
.
VI. PRACTICE INFORMATION
Name of Primary Practice/Affiliation or Clinic:
Department Name (if hospital based):
Primary Clinical Practice Street Address:
Effective Date at Location, Month / Year:
City:
County:
State:
ZIP:
Primary Office Telephone Number:
( ) - Ext
Primary Office Fax Number:
( ) -
Patient Appointment Telephone Number:
( ) - Ext
Mailing
/
Billing Address (if different from above):
Attn:
Office Manager:
Office Manager’s Telephone Number:
( ) - Ext
Office Manager’s Fax Number:
Exchange / Answering Service Number:
( ) - Ext
Pager Number:
( ) -
Office Email Address:
Credentialing Contact and Address (if different from above):
Credentialing Contact’s Telephone Number:
( ) - Ext
Credentialing Contact’s Fax Number:
( ) -
Credentialing Contact’s Email Address:
Federal Tax ID Number or Social Security Number, if used for business purposes:
Name Affiliated with Tax ID Number:
Name of Secondary Practice/Affiliation or Clinic:
Department Name (if hospital based):
Secondary Clinical Practice Street Address:
Effective Date at Location,
Month / Year:
City:
County:
State:
ZIP:
Secondary Office Telephone Number:
( ) - Ext
Secondary Office Fax Number:
( ) -
Patient Appointment Telephone Number:
( ) - Ext
Mailing
/
Billing Address (if different from above):
Attn:
Office Manager:
Office Manager’s Telephone Number:
( ) - Ext
Office Manager’s Fax Number:
( ) -
Exchange / Answering Service Number:
( ) - Ext
Pager Number:
( ) -
Office Email Address:
Credentialing Contact and Address (if different from above):
Credentialing Contact’s Telephone Number:
( ) - Ext
Credentialing Contact’s Fax Number:
( ) -
Credentialing Contact’s Email Address:
Federal Tax ID Number or Social Security Number, if used for business purposes:
Name Affiliated with Tax ID Number:
Please list other office locations with above information on a separate sheet.
After hours primary care coverage
This form must be completed to be considered for PCP designation with Moda Health.
1. Dat
e: _______________________
2. Do you currently provide primary care coverage for your patients 24 hours a day, seven days a week,
365 days a year?
Yes
No
If you answered Yes to the above question, please complete this form for PCP credentialing.
In order to qualify for PCP designation, a provider must have after-hours primary care coverage and share
primary care call with a Moda Health participating provider. The covering provider must also qualify for and be
designated as a PCP with Moda Health.
Appropriate examples of after hours coverage include:
- After hours answering service
- Cell phone/pager number on voicemail greeting where patients can reach you after hours
Please outline a description of your after-hours primary care coverage plan:
Nam
e of provider/applicant: ___________________________________________________________________
Pro
vider/applicant signature: _______________________________________ Date: ______________________
Oregon Practitioner Credentialing Application
5/1/12
Page 4 of 12 INITIALS: ____________DATE: _____________________________
VII. PRACTICE CALL COVERAGE
Please provide the name and specialty of those practitioners who
provide care for your patients when you are unavailable.
NAME
:
SPECIALTY:
1.
2.
3.
4.
5.
VIII. UNDERGRADUATE EDUCATION
Please attach additional sheets, if necessary.
Complete School Name:
Degree Received:
Month / Year of Graduation:
City:
State:
Course of Study or Major:
IX. GRADUATE EDUCATION
Please attach additional sheets, if
necessary.
Does Not Apply
Complete School Name:
Degree Received:
Month / Year of Graduation:
City:
State:
Course of Study or Major:
X. MEDICAL / PROFESSIONAL EDUCATION
Please attach additional sheets, if necessary.
Complete Medical / Professional School Name and Street Address:
City:
State
ZIP:
Degree Received:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program? Yes No (If you did not complete the program, please explain on a separate sheet.)
Complete Medical / Professional School Name and Street Address:
City:
State:
ZIP:
Degree Received:
Phone Number:
( ) - :
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
Oregon Practitioner Credentialing Application
5/1/12
Page 5 of 12 INITIALS: ____________DATE: _____________________________
XI.
POST-GRADUATE YEAR 1 / INTERNSHIP
Please attach additional sheets, if necessary.
Does Not Apply
Complete Institution Name and Street Address:
City:
State:
ZIP:
Type of Internship / Specialty:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
XII. RESIDENCIES
Please attach additional sheets, if necessary.
Does Not Apply
Complete Institution Name and Street Address:
City:
State:
ZIP:
Specialty:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
Complete Institution Name and Street Address:
City:
State:
ZIP:
Specialty:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
XIII.
FELLOWSHIPS, PRECEPTORSHIPS, OR OTHER CLINICAL
TRAINING PROGRAMS
Please attach additional sheets, if necessary.
Does Not Apply
Complete Institution Name and Street Address:
City:
State:
ZIP:
Specialty:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
Complete Institution Name and Street Address:
City:
State:
ZIP:
Specialty:
Phone Number:
( ) -
Fax Number, if available
( ) -
From Month / Year:
To Month / Year:
Month / Year of Completion:
Did you complete the program?
Yes No
(If you did not complete the program, please explain on a separate sheet.)
Oregon Practitioner Credentialing Application
5/1/12
Page 6 of 12 INITIALS: ____________DATE: _____________________________
XIV.
HEALTH CARE LICENSURE, REGISTRATIONS, CERTIFICATES &
ID NUMBERS
Please attach additional sheets, if necessary.
Oregon License or Registration Number:
Type:
Month / Day / Year of Expiration:
Drug Enforcement Administration (DEA) Registration Number (if applicable):
Month / Day / Year of Expiration:
Controlled Substance Registration (CSR) Number (if applicable):
Month / Day / Year of Issue:
Individual NPI Number:
Medicare Number:
DMAP Number:
XV.
OTHER STATE HEALTH CARE LICENSES, REGISTRATIONS
& CERTIFICATES
Please include all ever held.
Does Not Apply
State / Country:
Number:
Type:
Year Obtained:
Month / Day / Year of Expiration:
Year Relinquished:
Reason:
State / Country:
Number:
Type:
Year Obtained:
Month / Day / Year of Expiration:
Year Relinquished:
Reason:
State / Country:
Number:
Type:
Year Obtained:
Month / Day / Year of Expiration:
Year Relinquished:
Reason:
State / Country:
Number:
Type:
Year Obtained:
Month / Day / Year of Expiration:
Year Relinquished:
Reason:
State / Country:
Number:
Type:
Year Obtained:
Month / Day / Year of Expiration:
Year Relinquished:
Reason:
Please attach additional sheets, if necessary.
Oregon Practitioner Credentialing Application
5/1/12
Page 7 of 12 INITIALS: ____________DATE: _____________________________
XVI. HOSPITAL AND OTHER HEALTH CARE FACILITY AFFILIATIONS
Please list in reverse chronological order, with the current affiliation(s) first, all health care institutions where you have and/or
have had clinical privileges and/or staff membership. Include (A) current affiliations, (B) applications in process, and (C) previous
hospitals, and other facility affiliations (e.g., hospitals, surgery centers or any other health care related facility). If more space is needed,
please attach additional sheets. Do not list residencies, internships or fellowships. Please list employment in Section XVII,
Professional Practice/Work History.
A.
CURRENT AFFILIATIONS
Does Not Apply
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status (e.g. active, courtesy, provisional,
allied health, etc.):
Month / Day / Year of Appointment
Facility Name: Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status:
Month / Day / Year of Appointment
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status:
Month / Day / Year of Appointment
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status:
Month / Day / Year of Appointment
If you do not have hospital admitting privileges, check here
:
Please explain on a separate sheet your plan for continuity of care for your patients who require admitting.
B.
APPLICATIONS IN PROCESS
Does Not Apply
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status (e.g. active, courtesy, provisional,
allied health, etc.):
Month / Day / Year of Submission:
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
Status:
Month / Day / Year of Submission:
C.
PREVIOUS AFFILIATIONS
Please attach additional sheets, if necessary.
Does Not Apply
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
From Month / Day / Year:
To Month / Day / Year:
Reason for Leaving:
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
From Month / Day / Year:
To Month / Day / Year:
Reason for Leaving:
Facility Name:
Phone Number:
( ) -
Fax Number, if available
( ) -
Complete Address:
From Month / Day / Year:
To Month / Day / Year:
Reason for Leaving:
Oregon Practitioner Credentialing Application
5/1/12
Page 8 of 12 INITIALS: ____________DATE: _____________________________
XVII.
PROFESSIONAL PRACTICE / WORK HISTORY
Curriculum vitae is not sufficient.
Does Not Apply
A.
Please account for all periods of time from the date of entry into medical/professional school to present.
Chronologically list all work, professional and practice history activities since completion of postgraduate training,
including military service. Please explain in section B any gaps greater than two (2) months. Please attach additional
sheets, if necessary.
Name of Current Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Name of Previous Practice / Employer:
Contact’s Name:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Complete Address:
From Month / Year:
To Month / Year:
Contact’s Email Address, if available:
Professional Liability Carrier:
Oregon Practitioner Credentialing Application
5/1/12
Page 9 of 12 INITIALS: ____________DATE: _____________________________
B.
Please explain any gaps greater than two (2) months. Include activities and/or names and
dates where applicable. Please attach additional sheets, if necessary
.
Does Not Apply
Activities and/or Names: From Month / Year: To Month / Year:
XVIII. PEER REFERENCES
Please list three (3) references, from peers who through recent observations are directly familiar with your clinical skills and
current competence. Do not include relatives. If possible, include at least one member from the Medical Staff of each facility at
which you have privileges.
Name of Reference:
Complete Address, include Department if applicable:
Specialty:
Professional Relationship:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Email Address, if available:
Name of Reference:
Complete Address, include Department if applicable:
Specialty:
Professional Relationship:
Telephone Number:
( ) - (Ext
Fax Number:
( ) -
Email Address, if available:
Name of Reference:
Complete Address, include Department if applicable:
Specialty:
Professional Relationship:
Telephone Number:
( ) - Ext
Fax Number:
( ) -
Email Address, if available:
XIX.
CONTINUING MEDICAL EDUCATION
Please list activities for which you have received CME credit(s) during the past two (2) years.
Please attach a separate sheet, if needed.
Does Not Apply
Name:
Month / Year Attended:
Hours:
Name:
Month / Year Attended:
Hours:
Name:
Month / Year Attended:
Hours:
Name:
Month / Year Attended:
Hours:
Name:
Month / Year Attended:
Hours:
Name:
Month / Year Attended:
Hours:
Oregon Practitioner Credentialing Application
5/1/12
Page 10 of 12 INITIALS: ____________DATE: _____________________________
XX. PROFESSIONAL LIABILITY INSURANCE
Current Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number:
Type of Coverage (check one):
Claims
-
Made
Oc
currence
Name of Local Contact:
Mailing Address:
Contact’s Telephone Number:
( ) - Ext
Fax Number:
( ) -
Per claim limit of liability:
Aggregate amount:
Month / Day / Year Effective:
Month / Day / Year Retroactive Date, if applicable:
Month / Day / Year of Expiration:
Please list all previous professional liability carriers within the past five (5) years. Please
attach additional sheets, if necessary.
Does Not Apply
Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number:
Type of Coverage (check one):
Claims-Made Occurrence
Name of Local Contact:
Mailing Address:
Contact’s Telephone Number:
( ) - Ext
Fax Number:
( ) -
Per claim limit of liability:
Aggregate amount:
Month / Day / Year Effective:
Month / Day / Year Retroactive Date, if applicable:
Month / Day / Year of Expiration:
Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number:
Type of Coverage (check one):
Claims-Made Occurrence
Name of Local Contact:
Mailing Address:
Contact’s Telephone Number:
( ) - Ext
Fax Number:
( ) -
Per claim limit of liability:
Aggregate amount:
Month / Day / Year Effective:
Month / Day / Year Retroactive Date, if applicable:
Month / Day / Year of Expiration:
Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number:
Type of Coverage (check one):
Claims-Made
Occurrence
Name of Local Contact:
Mailing Address:
Contact’s Telephone Number:
( ) - Ext
Fax Number:
( ) -
Per claim limit of liability:
Aggregate amount:
Month / Day / Year Effective:
Month / Day / Year Retroactive Date, if applicable:
Month / Day / Year of Expiration:
Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number:
Type of Coverage (check one):
Claims-Made
Occurrence
Name of Local Contact:
Mailing Address:
Contact’s Telephone Number:
( ) - Ext
Fax Number:
( ) -
Per claim limit of liability:
Aggregate amount:
Month / Day / Year Effective:
Month / Day / Year Retroactive Date, if applicable:
Month / Day / Year of Expiration:
Oregon Practitioner Credentialing Application
5/1/12
Page 11 of 12 INITIALS: ____________DATE: _____________________________
XXI.
ATTESTATION QUESTIONS
– This section to be completed by the Practitioner.
Modification to the wording or format of these Attestation Questions will invalidate the application.
Please answer the following questions “yes” or “no”. If your answer to any of the following questions is “yes”, please provide details
and reasons, as specified in each question, on a separate sheet. Please sign and date each additional sheet.
A
.
Has your license, certification, or registration to practice your profession, Drug Enforcement Administration (DEA)
registration, or narcotic registration/certificate in any jurisdiction ever been denied, limited, suspended, revoked, not
renewed, voluntarily or involuntarily relinquished, or subject to stipulated or probationary conditions, had a corrective
action, or have you ever been fined or received a letter of reprimand or is any such action pending or under review?
YES
NO
B.
Have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded for any reasons, by
Medicare, Medicaid, or any public program or is any such action pending or under review?
YES
NO
C.
Have you ever been denied clinical privileges, membership, or contractual participation by any health care related
organization
*,
or have clinical privileges, membership, participation or employment at any such organization ever
been placed on probation, suspended, restricted, revoked, voluntarily or involuntarily relinquished or not renewed, or
is any such action pending or under review?
YES
NO
D.
Have you ever surrendered clinical privileges, accepted restrictions on privileges, terminated contractual participation
or employment, taken a leave of absence, committed to retraining, or resigned from any health care related
organization
*
while under investigation or potential review?
YES
NO
E.
Has an application for clinical privileges, appointment, membership, employment or participation in any health care
related organization* ever been withdrawn on your request prior to the organization’s final action?
YES
NO
F.
Has your membership or fellowship in any local, county, state, regional, national, or international professional
organization ever been revoked, denied, limited, voluntarily or involuntarily relinquished or not renewed, or is any
such action pending or under review?
YES
NO
G
Have you
ever
voluntarily or involuntarily left or been discharged from medical school or subsequent training
programs?
YES
NO
H
Have you ever had board certification revoked?
YES
NO
I
Have you ever been the subject of any reports to a state or federal data bank or state licensing or disciplinary entity?
YES
NO
J.
Have you ever been charged with a criminal violation (felony or misdemeanor)?
YES
NO
K
.
Do you presently use any illegal drugs?
YES
NO
L
Do you now have, or have you had, any physical condition, mental health condition, or chemical dependency condition
(alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice, with or without
reasonable accommodation, the privileges requested?
YES
NO
If reasonable accommodation is required, please specify the accommodation(s) required on a separate sheet.
M
Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner
agreement/hospital appointment, with or without reasonable accommodation, according to accepted standards of
professional performance?
YES
NO
N.
Have any professional liability claims or lawsuits ever been closed and/or filed against you?
YES
NO
If yes, please complete
Attachment A, Pr
ofessional Liability Action Detail,
for
each
past or current claim and/or
lawsuit.
O
.
Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced
limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance?
YES
NO
*e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO),
preferred provider organization (PPO), physician hospital organization (PHO), medical society, professional association, health care faculty
position or other health delivery entity or system
I certify the information in this entire application is complete, current, correct, and not misleading. I understand and acknowledge that any
misstatements in, or omissions from this application will constitute cause for denial of my application or summary dismissal or termination of my
clinical privileges, membership or practitioner participation agreement. A photocopy of this application, including this attestation, the authorization
and release and any or all attachments has the same force and effect as the original. I have reviewed this information on the most recent date indicated
below and it continues to be true and complete. While this application is being processed, I agree to update the information originally provided in this
application should there be any change in the information.
I agree to provide continuous care for my patients, until the practitioner/patient relationship has been properly terminated by either party, or in
accordance with contract provisions.
Signature:
Date:
Oregon Practitioner Credentialing Application
5/1/12
Page 12 of 12 INITIALS: ____________DATE: _____________________________
OREGON PRACTITIONER CREDENTIALING APPLICATION
AUTHORIZATION AND RELEASE OF INFORMATION FORM
Modified Releases Will Not Be Accepted
By submitting this application, I understand and agree to the following:
1. I understand and acknowledge that, as an applicant for medical staff membership at the designated hospital(s) and/or participation status with
the health care related organization(s) [e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health
maintenance organization (HMO), preferred provider organization (PPO), physician hospital organization (PHO), medical society,
professional association, medical school faculty position or other health delivery entity or system] indicated on this application , I have the
burden of producing adequate information for proper evaluation of my competence, character, ethics, mental and physical health status, and
other qualifications. In this application, I have provided information on my qualifications, professional training and experience, prior and
current licensure, Drug Enforcement Agency registration and history, and applicable certifications. I have provided peer references familiar
with my professional competence and ethical character, if requested. I have disclosed and explained any past or pending professional corrective
action, licensure limitations or related matter, if any. I have reported my malpractice claims history, if any, and have attached or will provide a
copy of a current certificate of professional liability coverage.
2. I further understand and acknowledge that the health care related organization(s) or designated agent would investigate the information in this
application. By submitting this application, I agree to such investigation and to the disciplinary reporting and information exchange activities of
the health care related organization(s) as a part of the verification and Credentialing process.
3.
I authorize all individuals, institutions, entities of other hospitals or institutions with which I have been associated and all professional liability
insurers with which I have had or currently have professional liability insurance, who may have information bearing on my professional
qualifications, ethical standing, competence, and mental and physical health status, to consult with the designated health care related
organization(s), their staffs and agents.
4. I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry out the
clinical privileges/services I request. I authorize each and every individual and organization in custody of such records and documents to permit
such inspection and copying. I am willing to make myself available for interviews, if required or requested.
5. I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction with
investigating and evaluating my application and qualifications, and I waive all legal claims against any representative of the health care related
organization(s) or their respective agent(s) who acts in good faith and without malice in connection with the investigation of this application.
6. I understand and agree that the authorizations and releases given by me herein shall be valid so long as I am an applicant for or have medical
staff membership and/or clinical privileges/participation status at the health care related organization(s) designated herein, unless revoked by me
in writing.
7. For hospital or medical staff membership/clinical privileges, I acknowledge that I have been informed of, and hereby agree to abide by, the
medical staff bylaws, rules, regulations and policies.
8. I agree to exhaust all available procedures and remedies as outlined in the bylaws, rules, regulations, and policies, and/or contractual agreements
of the health care related organization(s) where I have membership and/or clinical privileges/participation status before initiating judicial action.
9. I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and Release
shall be as effective as the original and authorization constitutes my written authorization and request to communicate any relevant information
and to release any and all supportive documentation regarding this application.
Printed Name:
Signature:
Date:
I grant permission for the release of the credentials information contained in this practitioner application
to the following health care related organization(s):
Modification to the wording or format of the Oregon Practitioner Credentialing Application will invalidate the application.
ATTACHMENT A
PROFESSIONAL LIABILITY ACTION DETAIL – CONFIDENTIAL
Please list any past or current professional liability claim or lawsuit, which has been filed against you.
Photocopy this page as needed and submit a separate page for EACH professional liability
claim/lawsuit. It is not acceptable to simply submit court documents in lieu of completing this document.
Please complete each field. Please attach additional sheet(s), if necessary.
Practitioner’s Name (print or type):
Month / Day / Year of the incident: and clinical details:
Your role and specific responsibilities in the incident:
Subsequent events, including patient’s clinical outcome:
Month / Day / Year the suit or claim was filed:
Name and address of insurance carrier/professional liability provider that handled the claim:
Your status in the legal action (primary defendant, co-defendant, other):
Current status of suit or other action:
Month / Day / Year of settlement, judgment, or dismissal:
If case was settled out-of-court, or with a judgment, settlement amount attributed to you:
I verify the information contained in this form is correct and complete to the best of my knowledge.
Signature: Date:
Modification to the wording or format of the Oregon Practitioner Credentialing Application will invalidate the application.
Jim Rickard, MD
Med
ical Director
Last Name: First: Middle:
Do you want to be designated as a Primary Care Practitioner? Yes No
Yes No
Do you currently have admitting privileges?
If you answered “No” to the above question, please outline a description of your action plan for patients that
need to be admitted to a hospital.
SECLUSION & RESTRAINT (CFR, 438.100)
Does your office have a policy and procedure related to the use of seclusion and restraint as required under
the Code of Federal Regulations? Yes No
If you do not have a policy, please describe the actions you would take in the event there were a disruptive
individual/s in your office to ensure that you do not seclude or restrain, ie; Call 911.
Our Office Process:___________________________________________________________________
After Hours PCP Coverage: If you answered “Yes” to the above question, please complete this section
credentialing.
Admitting Arrangement
Do you currently provide primary care coverage for your patients 24 hours a day, seven days a week, 365
days a year?
Yes No
In order to qualify for PCP designation, a provider must have after-hours primary care coverage and share
primary care call with a Moda Health participating provider. The covering provider must also qualify for
and be designated as a PCP with Moda Health.
Appropriate examples of after hours coverage include:
After hours answering service
Cell phone/pager number on voicemail greeting where patients can reach you after hours
Name of provider/applicant:
Provider/applicant signature:
Date:
Identifying Information
PCP Designation
IMPORTANT
Credentialing Application Addendum.
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