Get Or Moda Health Oregon Practitioner Credentialing Application 2012-2025

This guide provides clear and supportive instructions to assist you in completing the OR Moda Health Oregon Practitioner Credentialing Application online. By following these steps, you will ensure that your application is accurate, complete, and ready for submission.

Follow the steps to complete your credentialing application effectively.

1. Press the ‘Get Form’ button to access the Oregon Practitioner Credentialing Application and open it in your preferred editing platform.
2. Begin with personal information: Enter your full legal name including any suffix, contact details, and citizenship status. Make sure to provide accurate information, particularly your social security number and birth date.
3. Fill in your specialty information: Indicate your principal clinical specialty and check any additional practice specialties. Specify if you wish to be designated as a primary care practitioner (PCP).
4. Continue with board certification: List all current and past certifications, including issuing board details and certification dates. If not currently certified, describe your intentions regarding future certification.
5. Provide practice information: Detail your primary and secondary practice locations, including contact details and your effective dates at these locations.
6. List your hospital and health care facility affiliations: Include both current and previous affiliations in reverse chronological order, indicating the status of each.
7. Document your professional practice and work history: Account for all periods from the date of your professional training until now. Ensure to explain any gaps lasting more than two months.
8. Add peer references: List three professional peers familiar with your clinical skills, making sure not to include relatives.
9. Complete the attestation questions: Respond to each question truthfully and ensure to provide any necessary additional details on separate sheets.
10. Finish the application: Sign and date the attestation and authorization sections on the last pages. Review your application for completeness and accuracy.
11. Finally, save your changes, and either download, print, or share the completed document as required for submission.

Get started now by completing your OR Moda Health Oregon Practitioner Credentialing Application online!