Provider Credentialing ApplicationPractice NamePerson Completing This FormContact PhoneContact EmailPractitioner NamePractitioner EmailNPIPECOS login information: (needed to file your Medicare applicationPECOS UsernamePECOS PasswordDOBGender Male FemaleSocial Security #Do you have a complete CAQH Profile Yes No I Don't KnowCAQH UsernameCAQH PasswordPrimary Office LocationPrimary Office StreetPrimary Office City, ST ZipPrimary Office PhonePersonal InformationHome AddressCity, ST ZipPhoneMarital Status- Select -SingleMarriedDivorcedWidowedOther Names UsedCity of BirthState of BirthCountry of BirthActive, Discharged, Retired Military Yes NoEducation & Training WE MUST HAVE MM/YYYY FOR EACH EDUATION & TRAINING ENTRY All Education & Training is shown on CV Yes NoDo you want to list any Professional Associations? Yes NoProfessional Associations LanguagesList any foreign languagesBoard / SpecialtyPCP or Specialist PCP SpecialistPrimary SpecialtyBoard Certified (Primary Specialty) Yes No2nd Specialty? Yes NoNotes about Board/Specialty section, such as additional specialties, information about expiration, etc Hospital Affiliations Please provide any details that are not included on your CV. Ensure that all entries include complete dates and full addresses. This information is essential for us to move forward with your credentialing process at Med Revenue Group. Without these details, we cannot begin your credentialing. Kindly complete the required information for each item below. Let us know if you need assistance!Are Complete Affiliation details including start/end date on your CV? Yes NoThen please complete the information for each present and past hospital affiliationProfessional Licensure Information License TypeLicense NumberIssuing BoardIssue StateIssue DateExpiration DateRestrictionsStatus- Select -ActiveInActiveLicense TypeLicense NumberIssuing BoardIssue StateIssue DateExpiration DateRestrictionsStatus- Select -ActiveInActiveECFMG NumberDate IssuedDEA NumberExpiration DateStatus- Select -ActiveInActiveCDS Number (state controlled dangerous substance certificate)StateExpiration DateStatus- Select -ActiveInActiveSpecial Certifications (CPR, BLS, ACLS, etc) Certified In- Select -ACLSBCLSCPRCertification NumberStart DateEnd DateCertified ByCertified In- Select -ACLSBCLSCPRCertification NumberStart DateEnd DateCertified ByNotes of other certificationsMedicare IDMedicaid IDProfessional Liability Insurance Provide insurance history for the last 10 years, or since you began practice if practicing less than 10 years. Provide information on any non-current policies for which you are not sending a copy of your Certificate of Insurance. Current Policy NumberCarrierCoverage FromCoverage To-Select-Claims MadeTail CoverageSingle LimitsAggregate LimitsExclusionsStatus- Select -ActiveInActiveDo you have other coverage to report? Yes NoProfessional Experience Please provide any details that are not included on your CV. Ensure that all entries include complete dates and full addresses. This information is essential for us to move forward with your credentialing process at Med Revenue Group. Without these details, we cannot begin your credentialing. Kindly complete the required information for each item below. We must have a minimum of 7 years work history. Is your complete work history shown on your CV Yes NoProfessional Experience Please provide any details that are not included on your CV. Ensure that all entries include complete dates and full addresses. This information is essential for us to move forward with your credentialing process at Med Revenue Group. Without these details, we cannot begin your credentialing. Kindly complete the required information for each item below. We must have 3 references with complete contact information. Reference #1 Title- Select -Dr.Mr.Mrs.Ms.UnknownFull NameSuffixProfessional SuffixStreet AddressCity, ST ZipCountryPhoneFaxEmailDates of Association FromToReference #2Dropdown- Select -Dr.Mr.Mrs.Ms.UnknownFull NameSuffixProfessional SuffixStreet AddressCity, ST ZipCountryPhoneFaxEmailDates of AssociationFromToReference #3Dropdown- Select -Dr.Mr.Mrs.Ms.UnknownFull NameSuffixProfessional SuffixStreet AddressCity, ST ZipCountryPhoneFaxEmailDates of Association FromToATTESTATION QUESTIONS - All are required Licensure 1) Has your license to practice in your profession ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board? Yes No2) Have you ever received a reprimand or been fined by any state licensing board? Yes NoHospital Privileges and Other Affiliations3) Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board? Yes No4) Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? Yes No5) Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? Yes NoEducation, Training and Board Certification6) Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? Yes No7) Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes No8) Have any of your board certifications or eligibility ever been revoked? Yes No9) Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? Yes NoDEA or CDS 10) Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished? Yes NoMedicare, Medicaid or other Governmental Program Participation 11) Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes NoOther Sanctions or Investigations 12) Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program? Yes No13) To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? Yes No14) Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? Yes No15) Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency? Yes NoMalpractice Claims History 16) Have you had any malpractice actions within the past 10 years (pending, settled, arbitrated, mediated, or litigated)? If yes, provide information for each case. Yes No17) Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? Yes No18) Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history? Yes NoCriminal 19) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional? Yes No20) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense? Yes No21) Have you ever been court-martialed for actions related to your duties as a medical professional? Yes NoAbility to Perform Job 22) Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Feral law." The term does include, however, the unlawful use of prescription controlled substances. Yes No23) Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? Yes No24) Do you have any reason to believe that you would pose a risk to the safety or well being of your patients? Yes No25) Are you unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation? Yes NoTo help expedite your credentialing process, you may upload the necessary documents at this time. These documents are essential for completing your credentialing file and ensuring we have all the required information to deliver accurate and efficient enrollment services. Please note that not all documents may be applicable to every provider.Required Documents:Active State Medical License(s)Malpractice Insurance Certificate (COI)DEA Registration and State CDS Certificate(s)Board Certification(s)Copy of Diploma (highest degree earned – M.D., D.O., MSN, etc.)Certificates of Completion for Internship, Residency, and FellowshipUpdated Curriculum Vitae (including current employer and dates in MM/YYYY format)Completed IRS Form W-9Valid Government-Issued Photo ID (e.g., Driver’s License)Voided Cheque and Bank LetterAdditional Documents (if applicable):ECFMG Certificate (for internationally educated providers)Passport or Proof of U.S. Citizenship (if born outside the U.S.)Upload Your Documents Below to begin the credentialing process with Med Revenue Group.Submit Form Upload fileDrag and Drop (or) Choose FilesSend Message Join Med Revenue Group Today! Join Now ‹›
