Provider Credentialing Application

Practice Name *

Person Completing This Form *

Contact Phone# *

Contact Email *

Practitioner Name

Practitioner Email

NPI

PECOS login information: (needed to file your Medicare application)

PECOS Username *

PECOS Password *

DOB

GenderMaleFemale

Social Security #

Do you have a complete CAQH ProfileYesNoI Don't Know

CAQH Username *

CAQH Password *

Primary Office Location

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Marital Status

Other Names Used

City of Birth

State of Birth

Country of Birth

Active, Discharged, Retired MilitaryYesNo

Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUATION & TRAINING ENTRY

All Education & Training is shown on CVYesNo

Do you want to list any Professional Associations?YesNo

Professional Associations Languages

List any foreign languages

Board / Specialty

PCP or SpecialistPCPSpecialist

Primary Specialty

Board Certified (Primary Specialty)YesNo

Notes 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?YesNo

Consent *

Yes, I agree with the privacy policy and terms and conditions.

Text

Consent

Yes, I agree with the privacy policy and terms and conditions.

Then please complete the information for each present and past hospital affiliation

Professional Licensure Information

License Type

License Number

Issuing Board

Issue State

Issue Date

Expiration Date

Restrictions

Select

License Type

License Number

Issuing Board

Issue State

Issue Date

Expiration Date

Restrictions

Select

ECFMG Number

Date Issued

DEA Number

Expiration Date

Select

CDS Number (state controlled dangerous substance certificate)

State

Expiration Date

Select

Special Certifications (CPR, BLS, ACLS, etc)

Select

Certification Number

Start Date

End Date

Certified By

Select

Certification Number

Start Date

END Date

Certified By

Notes of other certifications

Medicare ID

Medicaid ID

Professional 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 Number

Carrier

Coverage From

Coverage To

Select

Single Limits

Aggregate Limits

Exclusions

Select

Do you have other coverage to report?YesNo

Professional 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 CVYesNo

Professional Experience

We must have 3 references with complete contact information.

Reference #1

Select

Full Name

Suffix

Professional Suffix

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Fax

Email Address

Dates of Association

From

Reference #2

Select

Full Name

Suffix

Professional Suffix

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Fax

Dates of Association

From

Reference #3

Select

Full Name

Suffix

Professional Suffix

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Fax

Email Address

Dates of Association

From

ATTESTATION 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? *YesNo

Have you ever received a reprimand or been fined by any state licensing board? *YesNo

Hospital Privileges and Other Affiliations

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? *YesNo

Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? *YesNo

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)? *YesNo

Education, Training and Board Certification

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? *YesNo

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? *YesNo

Have any of your board certifications or eligibility ever been revoked?YesNo

Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? *YesNo

DEA or CDS

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? *YesNo

Medicare, Medicaid or other Governmental Program Participation

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? *YesNo

Other Sanctions or Investigations

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? *YesNo

To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? *YesNo

Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? *YesNo

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? *YesNo

Malpractice Claims History

Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? *YesNo

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? *YesNo

Criminal

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? *YesNo

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? *YesNo

Have you ever been court-martialed for actions related to your duties as a medical professional? *YesNo

Ability to Perform Job

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. *YesNo

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 *YesNo

Do you have any reason to believe that you would pose a risk to the safety or well being of your patients? *YesNo

Are you unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation? *YesNo

To 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 Fellowship
Updated Curriculum Vitae (including current employer and dates in MM/YYYY format)
Completed IRS Form W-9
Valid Government-Issued Photo ID (e.g., Driver’s License)
Voided Cheque and Bank Letter

Additional 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.

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