Get Standardized Credentialing Form To Be Used By Health ...

This guide provides a comprehensive overview of how to complete the Standardized Credentialing Form tailored for health maintenance organizations. It aims to assist users in successfully navigating the online requirements, ensuring they provide all necessary information clearly and accurately.

Follow the steps to complete your credentialing form effectively.

1. Click the ‘Get Form’ button to access the Standardized Credentialing Form. This will open the document in your preferred online editor for filling out the required fields.
2. Begin by filling out the general information section. Provide your full name, home address, and contact information accurately. Include all other names you have used, your date of birth, and confirm your U.S. citizenship status.
3. Proceed to the office/practice information section. Specify your primary care participation status and provide details of your office address, tax identification number, and emergency contact information.
4. In the professional education section, list all medical schools you attended, including their addresses and dates of attendance. Include any gaps in your training, if applicable.
5. Complete the postgraduate training sections by detailing your internships and residencies, including the institutions' names and your status in those programs.
6. In the practice specialty section, indicate your primary and secondary specialties and include all relevant certifications, expiration dates, and board information.
7. Document your work history for the past ten years, ensuring to account for any gaps in employment. Clearly list the names of previous practices, addresses, and dates of employment.
8. Fill in the professional liability insurance information. Enter the current and previous carriers, along with policy numbers and dates of coverage.
9. Complete the malpractice claims history section by disclosing any claims involving your professional practice. Provide sufficient details for each claim or indicate if there are none.
10. Answer the additional information questions honestly, using 'Y' for yes, 'N' for no, or 'N/A' for not applicable, providing explanations as needed on a separate sheet.
11. Attach all necessary documentation such as certificates, insurance, and W9 forms as specified in the document. Ensure that all documentation is complete before submission.
12. Finally, review all sections carefully, make any necessary edits, and save changes. You can then download, print, or share the completed form as required.

Complete your Standardized Credentialing Form online to ensure a smooth application process.