NPI login information: (needed to file your Medicare application) Do you have a complete CAQH Profile? Active, Discharged, Retired Military Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUCATION & TRAINING ENTRY All Education & Training is shown on CV Do you want to list any Professional Associations? Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUCATION & TRAINING ENTRY Board Certified (Primary Specialty) Provide detailed items that are not contained on your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Again, DBN cannot begin your credentialing process without these details. Are Complete Affiliation details including start/end date on your CV? Then please complete the information for each present and past hospital affiliation Professional Licensure Information Special Certifications (CPR, BLS, ACLS, etc)
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. Do you have other coverage to report?
Provide detailed items that are not contained in your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Again, DBN cannot begin your credentialing process without these details.
We must have a minimum of 7 years of work history. Is your complete work history shown on your CV? 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?
2) Have you ever received a reprimand or been fined by any state licensing board?
Hospital Privileges and Other Affiliations
3) 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 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?
4) Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?
5) 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)?
Education, Training and Board Certification
6) 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?
7) 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?
8) Have any of your board certifications or eligibility ever been revoked?
9) Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?
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?
Medicare, 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?
Other 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?
13) To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?
14) Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?
15) 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?
Malpractice 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.
17) Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?
18) 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?
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?
20) 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?
21) Have you ever been court-martialed for actions related to your duties as a medical professional?
22) Are you currently engaged in the illegal use of drugs?
23) 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?
"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.
24) Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?
25) Are you unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?
You may upload the required document copies at this time to help speed up your application process. these documents are needed to complete your credentialing file so that we have all information necessary to provide you with enrollment services. Not all documents will apply to every practitioner.
Required Documents Include: 1) Practitioner License(s)2) Malpractice Insurance (Certificate of Insurance)3) DEA (federal) and state CDS certificates4) Board Certification(s)5) Diploma - a copy of highest level of education (M.D., D.O, MSN, etc)6) Certificates of completion for all medical training (internship, residency, fellowship)7) Current copy of CV (showing current employer and MM/YYYY on all education and experience)8) IRS Form W-99) Current driver's license
Other documents that may be applicable:1) ECFMG Certificate (if educated in a foreign country) 2) Passport or other citizenship documents (if born in another country) Upload your Required Documents
Upload supported file (Max 15MB)