Fillable Form 1: California Participating Physician Application

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Form 1: California Participating Physician Application

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California Participating Physician Application - 05/97 Page 1 of 10
Physician Name:
CONFIDENTIAL/PROPRIETARY
California Participating Physician
Application
This application is submitted to:MDI , herein, this Healthcare Organization
1
I. INSTRUCTIONS:
This form should be typed 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. Please do not use abbreviations when completing the application. Current copies of the following
documents must be submitted with this application:
•State Medical License(s) •Face Sheet of Professional Liability Policy or Certification
•DEA Certificate •Curriculum Vitae
•Board Certification (if applicable) •ECFMG (if applicable)
II. IDENTIFYING INFORMATION
Last Name:
First:
Middle:
Is there any other name under which you have been known? Name (s):
Home Mailing Address:
City:
State:
ZIP:
Home Telephone Number: ( )
Home Fax Number: ( )
E-Mail Address:
Pager Number: ( )
Birth Date:
Birth Place (City/State/Country):
Citizenship (If not a United States citizen, please include copy of
Alien Registration Card).
Social Security #:
Gender
2
: Male Female
Specialty:
Race/Ethnicity
2
(voluntary):
Subspecialties:
III. PRACTICE INFORMATION
Practice Name (if applicable):
Department Name (If Hospital Based):
Primary Office Street Address:
City:
State:
ZIP:
Telephone Number: ( )
Fax Number: ( )
Office Manager/Administrator:
Telephone Number: ( )
Fax Number: ( )
Name Affiliated with Tax ID Number:
Federal Tax ID Number:
1
As used in the Information Release/Acknowledgments Section of this application, the term "this Healthcare Organization" shall refer to the entity to which this application is submitted as identified above.
2
This information will be used for consumer information purposes only.
Print Form
California Participating Physician Application - 05/97 Page 2 of 10
Physician Name:
Secondary Office Street Address:
City:
State:
ZIP:
Office Manager/Administrator:
Telephone Number: ( )
Fax Number: ( )
Name Affiliated with Tax ID Number:
Federal Tax ID Number:
Tertiary Office Street Address:
City:
State:
ZIP:
Office Manager/Administrator:
Telephone Number: ( )
Fax Number: ( )
Name Affiliated with Tax ID Number:
Federal Tax ID Number:
Other Medical Interests in Practice, Research, etc.:
IV. PREMEDICAL EDUCATION (Attach additional sheets if necessary. Reference This Section Number and Title)
College or University Name:
Degree Received:
Date of Graduation:
(mm/yy)
Mailing Address:
City:
State:
ZIP:
V. MEDICAL/PROFESSIONAL EDUCATION (Attach additional sheets if necessary.
Reference This Section Number and Title)
Medical School:
Degree Received:
Date of Graduation:
(mm/yy)
Mailing Address:
City:
State & Country:
ZIP:
Medical/Professional School:
Degree Received:
Date of Graduation:
(mm/yy)
Mailing Address:
City:
State & Country:
ZIP:
POSTGRADUATE TRAINING AND EXPERIENCE
VI. INTERNSHIP/PGYI (Attach additional sheets if necessary. Reference This Section Number and Title)
Institution:
Program Director:
Mailing Address:
City:
State & Country:
ZIP:
Type of Internship :
Specialty:
From: (mm/yy)
To: (mm/yy
VII. RESIDENCIES/FELLOWSHIPS (Attach additional sheets if necessary. Reference This Section Number and Title)
California Participating Physician Application - 05/97 Page 3 of 10
Physician Name:
Include residencies, fellowships, preceptorships, teaching appointments (indicate whether clinical or academic), and postgraduate edu-
cation in chronological order, giving name, address, city and ZIP code, and dates. Include all programs you attended, whether or not
completed.
Institution:
Program Director:
Mailing Address:
City:
State:
ZIP:
Type of Training (eg. residency, etc.):
Specialty:
From: (mm/yy)
To: (mm/yy)
Did you successfully complete the program? Yes No (If "No," please explain on separate sheet.)
Institution:
Program Director:
Mailing Address:
City:
State:
ZIP:
Type of Training:
Specialty:
From: (mm/yy)
To: (mm/yy)
Did you successfully complete the program? Yes No (If "No," please explain on separate sheet.)
Institution:
Program Director:
Mailing Address:
City:
State:
ZIP:
Type of Training:
Specialty:
From: (mm/yy)
To: (mm/yy)
Did you successfully complete the program? Yes No (If "No," please explain on separate sheet.)
VIII. BOARD CERTIFICATION
Include certifications by board(s) which are duly organized and recognized by:
• a member board of the American Board of Medical Specialties
• a member board of the American Osteopathic Association
• a board or association with equivalent requirements approved by the Medical Board of California
• a board or association with an Accreditation Council for Graduate Medical Education of American Osteopathic Association approved
postgraduate training that provides complete training in that specialty or subspecialty
Name of Issuing Board:
Specialty:
Date Certified/Recertified:
Expiration Date (if any):
Have you applied for board certification other than those indicated above? Yes No
If so, list board(s) and date(s):
If not certified, describe your intent for certification, if any, and date of eligibility for certification on separate sheet.
IX. OTHER CERTIFICATIONS (E.G. FLUOROSCOPY, RADIOGRAPHY, ETC.)
(Attach additional sheets if necessary. Reference This Section Number and Title)
California Participating Physician Application - 05/97 Page 4 of 10
Physician Name:
Type:
Number:
Expiration Date:
Type:
Number:
Expiration Date:
X. MEDICAL LICENSURE/REGISTRATIONS (Remember to attach copies of documents)
California State Medical License Number:
Issue Date:
Expiration Date:
Drug Enforcement Administration (DEA) Registration Number:
Expiration Date:
Controlled Dangerous Substances Certificate (CDS) (if applicable):
Expiration Date:
ECFMG Number (applicable to foreign medical graduates):
Date Issued:
Valid Through:
Medicare UPIN/National Physician Identifier (NPI):
MediCal/Medicaid Number:
XI. ALL OTHER STATE MEDICAL LICENSES. List All Medical Licenses Now or Previously Held.
(Attach additional sheets if necessary. Reference This Section Number and Title)
State:
License Number:
Expiration Date:
State:
License Number:
Expiration Date:
State:
License Number:
Expiration Date:
XII. PROFESSIONAL LIABILITY (Remember to attach copy of professional liability policy or certification face sheet)
Current Insurance Carrier:
Policy Number:
Original effective date:
Mailing Address:
City:
State:
ZIP:
Per Claim Amount $
Aggregate Amount: $
Expiration Date:
Please list all of your professional liability carriers within the past seven years, other than the one listed above:
Name of Carrier:
Policy #:
From: (mm/yy)
To: (mm/yy)
Mailing Address:
City:
State:
ZIP:
Name of Carrier:
Policy #:
From: (mm/yy)
To: (mm/yy)
Mailing Address:
City:
State:
ZIP:
California Participating Physician Application - 05/97 Page 5 of 10
Physician Name:
Name of Carrier:
Policy #:
From: (mm/yy)
To: (mm/yy)
Mailing Address:
City:
State:
ZIP:
Name of Carrier:
Policy #:
From: (mm/yy)
To: (mm/yy)
Mailing Address:
City:
State:
ZIP:
XIII. CURRENT HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
Please list in reverse chronological order (with the current affiliation{s} first) all institutions where you have current affiliations (A) and have had
previous hospital privileges (B) during the past ten years. This includes hospitals, surgery centers, institutions, corporations, military assignments, or
government agencies.
A. CURRENT AFFILIATIONS (Attach additional sheets if necessary. Reference This Section Number and Title)
Name and Mailing Address of Primary Admitting Hospital:
City:
State:
ZIP:
Department/Status (active, provisional, courtesy, etc.):
Appointment Date:
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
Department/Status:
Appointment Date:
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
Department/Status:
Appointment Date:
If you do not have hospital privileges, please explain on Addendum A.
B. PREVIOUS AFFILIATIONS During Last Ten Years. (Attach additional sheets if necessary. Reference This Section Number
and Title)
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
From: (mm/yy)
To: (mm/yy)
Reason for Leaving:
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
From:
(mm/yy)
To:
(mm/yy)
Reason for Leaving:
California Participating Physician Application - 05/97 Page 6 of 10
Physician Name:
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
From:
(mm/yy)
To:
(mm/yy)
Reason for Leaving:
Name and Mailing Address of Other Hospital/Institution:
City:
State:
ZIP:
From:
(mm/yy)
To:
(mm/yy)
Reason for Leaving:
XIV. PEER REFERENCES
List three professional references, preferably from your specialty area, not including relatives, current partners or associates in practice. If possible,
include at least one member from the Medical Staff of each facility at which you have privileges.
NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through close working
relations.
Name of Reference:
Specialty:
Telephone Number: ( )
Mailing Address:
City:
State:
ZIP:
Name of Reference:
Specialty:
Telephone Number: ( )
Mailing Address:
City:
State:
ZIP:
Name of Reference:
Specialty:
Telephone Number: ( )
Mailing Address:
City:
State:
ZIP:
XV. WORK HISTORY (Attach additional sheets if necessary. Reference This Section Number and Title)
Chronologically list all work history activities since completion of postgraduate training (use extra sheets if necessary). This information must be
complete. A curriculum vitae is sufficient provided it is current and contains all information requested below. Please explain any gaps in professional
work history on a separate page.
Current Practice:
Contact Name:
Telephone Number: ( )
Fax Number: ( )
Mailing Address:
City:
State:
ZIP:
From: (mm/yy)
To: (mm/yy)
California Participating Physician Application - 05/97 Page 7 of 10
Physician Name:
Name of Practice /Employer:
Contact Name:
Telephone Number: ( )
Fax Number: ( )
Mailing Address:
City:
State:
ZIP:
From: (mm/yy)
To: (mm/yy)
Name of Practice /Employer:
Contact Name:
Telephone Number: ( )
Fax Number: ( )
Mailing Address:
City:
State:
ZIP:
From: (mm/yy)
To: (mm/yy)
California Participating Physician Application - 05/97 Page 8 of 10
Physician Name:
XVI. ATTESTATION QUESTIONS
Please answer the following questions "yes" or "no." If your answer to questions A through K is "yes," or if your answer to L is “no,” please provide
full details on separate sheet.
A. Has your license to practice medicine in any jurisdiction, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any
jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily
relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of
reprimand or is such action pending?
Yes No
B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you
voluntarily or involuntarily relinquished eligibility to provide services or accepted conditions on your eligibility to provide services, for reasons relating to possible
incompetence or improper professional conduct, or breach of contract or program conditions, by Medicare, Medicaid, or any public program, or is any such action
pending?
Yes
No
C. Have your clinical privileges, membership, contractual participation or employment by any medical organization (e.g. hospital medical staff, medical group,
independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those
that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system), ever been
denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach
of contract, or is any such action pending?
Yes No
D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual
participation or employment, or resigned from any medical organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health
plan, health maintenance organization (HMO), preferred provider organization (PPO), medical society, professional association, medical school faculty position or
other health delivery entity or system) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for
such an investigation not being conducted, or is any such action pending?
Yes No
E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship,
residency, fellowship, preceptorship, or other clinical education program?
Yes No
F. Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced,
limited, subjected to probationary conditions, or not renewed , or is any such action pending?
Yes No
G. Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing
from eligible to certified)?
Yes No
H. Have you ever been convicted of any crime (other than a minor traffic violation)?
Yes
No
I. Do you presently use any drugs illegally?
Yes No
J. Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases, or are there any
filed and served professional liability lawsuits/arbitrations against you pending?
Yes No
K. 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, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew,
or limit your professional liability insurance or its coverage of any procedures?
Yes No
L. Are you able to perform all the services required by your agreement with, or the professional staff bylaws of, the Healthcare Organization to which you are
applying, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of
patients?
Yes No
I hereby affirm that the information submitted in this Section XVI, Attestation Questions, and any addenda thereto is true, current, correct, and complete to the best
of my knowledge and belief and is furnished in good faith. I understand that material, omissions or misrepresentations may result in denial of my application or
termination of my privileges, employment or physician participation agreement.
Print Name Here:
Physician Signature______________________________________________________________________________________Date
(Stamped Signature Is Not Acceptable)
California Participating Physician Application - 05/97 Page 9 of 10
Physician Name:
INFORMATION RELEASE/ACKNOWLEDGMENTS
I hereby consent to the disclosure, inspection and copying of information and documents relating to my credentials, qualifications and
performance ("credentialing information") by and between "this Healthcare Organization” and other Healthcare Organizations (e.g., hospital
medical staffs, medical groups, independent practice associations {IPAs}, health plans, health maintenance organizations {HMOs}, preferred
provider organizations {PPOs}, other health delivery systems or entities, medical societies, professional associations, medical school faculty
positions, training programs, professional liability insurance companies {with respect to certification of coverage and claims history}, licensing
authorities, and businesses and individuals acting as their agents (collectively, "Healthcare Organizations"), for the purpose of evaluating this
application and any recredentialing application regarding my professional training, experience, character, conduct and judgment, ethics, and
ability to work with others. In this regard, the utmost care shall be taken to safeguard the privacy of patients and the confidentiality of patient
records, and to protect credentialing information from being further disclosed.
I am informed and acknowledge that federal and state
3
laws provide immunity protections to certain individuals and entities for their acts and/or
communications in connection with evaluating the qualifications of healthcare providers. I hereby release all persons and entities, including this
Healthcare Organization, engaged in quality assessment, peer review and credentialing on behalf of this Healthcare Organization, and all persons
and entities providing credentialing information to such representatives of this Healthcare Organization, from any liability they might incur for
their acts and/or communications in connection with evaluation of my qualifications for participation in this Healthcare Organization, to the extent
that those acts and/or communications are protected by state or federal law.
I understand that I shall be afforded such fair procedures with respect to my participation in this Healthcare Organization as may be required by
state and federal law and regulation, including but not limited to, California Business and Professions Code Section 809 et seq, if applicable.
I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional
competence, character, ethics and other qualifications and for resolving any doubt about such qualifications.
During such time as this application is being processed, I agree to update the application should there be any change in the information provided.
In addition to any notice required by any contract with a Healthcare Organization, I agree to notify this Healthcare Organization immediately in
writing of the occurrence of any of the following: (i) the unstayed suspension, revocation or nonrenewal of my license to practice medicine in
California; (ii) any suspension, revocation or nonrenewal of my DEA or other controlled substances registration; or (iii) any cancellation or
nonrenewal of my professional liability insurance coverage.
I further agree to notify this Healthcare Organization in writing, promptly and no later than fourteen (14) calendar days from the occurrence of any of
the following: (i) receipt of written notice of any adverse action against me by the Medical Board of California taken or pending, including but not
limited to, any accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to
practice medicine; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a Section 805 report with
the Medical Board of California, or a report with the National Practitioner Data Bank; or (iii) the denial, revocation, suspension, reduction,
limitation, nonrenewal or voluntary relinquishment by resignation of my medical staff membership or clinical privileges at any Healthcare
Organization; or (iv) any material reduction in my professional liability insurance coverage; or (v) my receipt of written notice of any legal action
against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding
minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including,
but not limited to, fraud and abuse proceedings or convictions.
I hereby affirm that the information submitted in this application and any addenda thereto (including my curriculum vitae if attached) is true,
current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material omissions or
misrepresentations may result in denial of my application or termination of my privileges, employment or physician participation agreement. A
photocopy of this document shall be as effective as the original, however, original signatures and current dates are required on pages 8 and 9.
Print Name Here
Physician Signature____________________________________________________________________________ Date
(Stamped Signature Is Not Acceptable)
3
The intent of this release is to apply at a minimum, protections comparable to those available in California to any action, regardless of where such action is brought.
California Participating Physician Application - 05/97 Page 10 of 10
Physician Name:
Addenda Submitting (Please check the following):
Addendum A - Health Plan and IPA/Medical Group
Addendum B - Professional Liability Action Explanation
This Application and Addenda A and B were created and are endorsed
by:
• American Medical Group Association - (310/430-1191 x223)
• California Association of Health Plans - (916/552-2910)
• California Healthcare Association - (916/552-7574)
• California Medical Association - (415/882-5166)
• National IPA Coalition - (510/267/1999)
• The Medical Quality Commission - (310/936-1100 x230)
Individual healthcare organizations may request additional information or attach supplements to this form. They are not part of the California
Participation Physician Reapplication nor have they been endorsed by the above organizations. Any questions about supplements should be
addressed to the health care organization from which it was provided.
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Form 1: California Participating Physician Application

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Completed 24 March 2021

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