Get Idph Recredentialing Application Word 061118

Filling out the Idph Recredentialing Application Word 061118 is an important step in the credentialing and recredentialing process. This guide provides a comprehensive overview of how to accurately complete the form online to ensure your application is processed smoothly.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Idph Recredentialing Application and open it in your preferred online editor.
2. Begin with the personal information section. Fill in your last name, first name, middle initial, degree, date of birth, DEA, tax ID number, UPIN, Medicare number, AHCCCS ID, gender, and any other names you have used. Make sure to double-check the spelling and accuracy of this information.
3. Proceed to the office address and credentialing contact information. Provide details about your group practice name, primary office address, additional office addresses, contact numbers, office hours, and credentialing contact information.
4. Complete the licensure information section. Include the state, license number, and dates first licensed in Arizona and the United States. Be thorough with all license information, including expiration dates.
5. Provide details regarding professional liability insurance. Attach a copy of the current policy's face sheet, including the name of the carrier, policy number, address, amounts of coverage, issue date, and expiration date.
6. List your education and training. Enter the names of institutions attended along with the dates in a month/year format.
7. Document your work history for the last five years. Use the month/year format for each position held, indicating the most recent employment first.
8. Fill out the current hospital affiliations section, detailing your status and dates of staff membership at each facility.
9. Complete the confidential questionnaire by answering each question with ‘yes’ or ‘no’. If any answers are 'yes', ensure you attach a separate sheet that explains the circumstances in detail.
10. Review and sign the declaration section, certifying that all information provided is correct and complete. Your signature confirms your understanding that any misstatements may impact your credentialing.
11. Finish by filling out the release of liability and information statement, then print or save the document. Make sure to include your name, signature, and the current date.
12. Based on your needs, you can save the form, download it for future reference, print a physical copy, or share it as required.

Complete your Idph Recredentialing Application online today for a smoother credentialing process.