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How to use or fill out the Updated Initial Credentialing Application - Non MD DO.doc online
Filling out the Updated Initial Credentialing Application - Non MD DO.doc online can be a straightforward process if you follow the steps carefully. This guide aims to provide clear and detailed instructions to help you complete each section of the application properly.
Follow the steps to successfully complete your application online.
- Press the ‘Get Form’ button to access the application and open it in your preferred editor.
- Begin with the 'Personal Information' section. Fill in your full name, including any previous names, and your date of birth. Ensure that all fields are completed to avoid any delays.
- Provide your residential address, contact numbers, email address, and any languages spoken other than English. Accuracy is key to ensure effective communication.
- In the 'Professional Information' section, indicate your specialties and provide details on your state license, federal tax ID, DEA number, and any relevant certifications. This section may include multiple licenses, so be sure to list all applicable credentials.
- Complete the 'Primary Plan Location for Dean Health Plan' with your office name, address, and contact details. Designate your clinic status, either full-time, part-time, or other.
- If applicable, fill in details for any additional office locations you may have, ensuring that each address and contact point is accurate.
- Provide comprehensive educational background, including undergraduate degrees and any specialty training. Ensure all dates attended are reflected accurately.
- In the 'Professional Career – Present and Past' section, list all work experiences chronologically, including the name and address of each practice, along with the start and end dates.
- Identify any gaps in your career and explain them briefly. This can include periods of education, personal matters, or other professional transitions.
- Complete the 'Professional Liability Carrier' section. You will need to present your current malpractice insurance information, effective dates, and maximum coverage limits.
- Respond to each question in the 'Professional Liability History' and 'Disciplinary Actions' sections honestly. If applicable, be prepared to submit additional documentation for any explanations required.
- Complete the 'Practitioner Attestation' by reviewing and confirming the accuracy of all provided information. Your signature will finalize this section.
- Once all sections are complete, review for accuracy and completeness. You can then save changes, download, or print the form as needed.
Complete your Updated Initial Credentialing Application online today!
Three essential pieces of information needed for credentialing include the provider's work history, proof of education, and the current state license. These elements are crucial to verify the applicant's professional background and competency. Moreover, having an Updated Initial Credentialing Application - Non MD DO.doc that is filled out accurately enhances the verification process. Consider using uslegalforms as a resource to gather and organize this critical information effectively.
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