Get Wv Credentialing Form

Completing the Wv Credentialing Form accurately is essential for any practitioner looking to maintain their medical licensure and credentials. This guide provides clear, step-by-step instructions to help you fill out the form online with confidence.

Follow the steps to successfully fill out the Wv Credentialing Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin filling out the 'Applicant Information' section. You will need to provide your last name, first name, middle name, and degree. Be sure to indicate your gender and date of birth, using 'N/A' for any fields that do not apply.
3. Complete the 'Office Practice Information' section. Specify whether your office is a primary or additional site and provide details including address, telephone numbers, and the type of practice you are operating.
4. In the 'Medical/Professional Education' section, list all educational institutions attended, along with the degrees received and dates of attendance. If you are an international graduate, make sure to attach your ECFMG Certificate.
5. Move to the 'Professional Training' section. Document any internships, residencies, or fellowships completed, detailing the training institution, specialty, and whether the program was successfully completed.
6. List all current and past professional licenses in the 'State License(s)' section. Indicate the status of each license and note any restrictions that may have been placed on them.
7. Complete the 'Certifications/Registrations' section, providing details about any applicable certifications, including DEA registrations, and submit copies as required.
8. Chat to the 'Professional Peer References' section. Provide names and contact details for at least three professional references who can validate your professional competencies.
9. Fill out the sections regarding 'Hospital/Health Care Entity Affiliations' and 'Work History/Experience'. Ensure gaps greater than three months are addressed in the designated section.
10. In the final sections, answer any liability and disclosure questions truthfully. After completing the form, ensure you sign and date it before submission.
11. Once all information is accurately filled in, save your changes. You may download, print, or share the completed Wv Credentialing Form as required.

Complete your Wv Credentialing Form online today to streamline your credentialing process.