Follow the steps to successfully fill out the Credentialing Application - Practitioner online.

1. Click ‘Get Form’ button to access the application and open it in your preferred digital editor.
2. Begin with the Practitioner Information section. Enter your last name, first name, middle initial, and any other name(s) you may have used. Specify your date of birth, taxpayer identification number, and confirm if you are a U.S. citizen.
3. For the Credentialing Contact Information, provide your preferred method of contact (email, phone, or mail). Include your street address, city, state, zip code, and any additional information like phone and fax numbers.
4. In the Professional License section, list all relevant licenses, including state, license number, and date issued. Ensure the information is accurate and current.
5. Fill out the Specialty/Sub-Specialty Board Certification section. Indicate whether you are board certified and provide details about the certifying board. If you are not board certified, explain why.
6. Complete the Professional Education and Training section, detailing your educational background, including any relevant internships, residencies, or fellowships.
7. Document your Clinical Employment/Practice History since completion of your postgraduate training in chronological order. Include phone numbers for validation if available.
8. Address the Malpractice Litigation and Professional Complaints section only if applicable. Provide details of any claims or lawsuits against you.
9. Answer the Disclosure Questions truthfully. Attach a separate sheet if you answer yes to any question that requires further explanation.
10. Read and complete the Standard Authorization, Attestation, and Release section. Ensure you understand its significance before signing.
11. Compile the Evidence of Credentials Checklist, ensuring that all necessary documentation is included and that nothing is expired. Check each item off as you compile them.
12. Once you have completed the application, upload it along with all required documents to the designated portal or send it to the provided address.

Complete your Credentialing Application - Practitioner online today to streamline your credentialing process.