New Doctor Credentialing Form

Dentist Information

First name *

Middle name

Last name *

Gender *

Date of birth *

SSN (Required for insurance enrollment)*

Are you a U.S citizen? *

If No, are you allowed to work in the U.S? *

When does your work visa expire? *

Birthplace (Country, State or Province) *

Languages other than English spoken by dentist *

Dentist's Signature ( Please provide a photo of your signature to be included on the application.) *

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CV showcasing 5 years of continuous work experience, presented in a clear month/year format. *

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Contact Information

Email Address *

Phone number *

Home or Mailing Address *

City *

State *

Zip Code *

Licensing & Professional Info

Dental License

State *

Dental License # *

Issued date *

Expiration date *

Do you have a Dental License in other states? *

Name of the State *

Other current dental license # *

Issued date *

Expiration date *

Current copy of dental license *

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DEA License

DEA License # *

Issued date *

Expiration date *

State *

Current copy of DEA license *

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Professional Liability Information (PLI)

PLI policy number *

Name of current carrier *

Effective date *

Expiration date *

Current copy of malpractice insurance *

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NPI number *

CAQH ID *

Do you have a CAQH username & password? *

CAQH username *

CAQH password *

Specialty *

Area of Specialty *

Orthodontist

Oral Surgeon

Periodontist

Prosthodontist

Endodontist

Pediatric Dentist

Specialty school name *

Specialty school's city *

Specialty school's state *

Specialty school's postcode / ZIP *

Specialty school start date *

Specialty school completion date *

Education & Background

Dental school name *

City *

State *

Zip Code*

Dental school start date *

Dental school completion date *

Dental degree awarded *

DMD

DDS

Other

Dental school other degree awarded *

Current copy of Diploma *

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Credentialing questionnaire

PLEASE NOTE: It is extremely important to answer these questions as open (and honestly) as possible. A "yes" answer will NOT hinder your chances of employment or credentialing acceptance. This questionnaire merely allows us to anticipate any potential problems that might occur in the credentialing process as well as getting your credentialing applications filled out accurately.

1. Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board? *

2. Has there been any challenge to your licensure, registration or certification? *

3. Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been suspended or limited or have you voluntarily terminated your participation? *

4. In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? *

5. Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? *

6. Have you ever had a judgment made against you for alleged malpractice, negligence, or related matters? *

7. Have you ever had a judgment made against you in a professional liability case or has your liability insurer placed any conditions or restrictions on your coverage or ability or attain coverage? *

8. Have you ever had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? If yes, provide information for each case? *

9. Are you or have you been under the treatment for the use of narcotics, barbiturates, alcohol, or other drugs? *

10. Do you presently have any physical or mental conditions that would adversely affect your ability to provide high quality professional services? Are there any accommodations that need to be considered? Please list accommodations below? *

11. Has your participation with a managed care organization, other health care organization, or hospital privileges been suspended, limited, or terminated? *

12. Has your Drug Enforcement Agency (DEA) registration been denied. revoked, suspended, or not renewed? *

13. Are you currently using illegal drugs or controlled substances? *

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

15. Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies? *

16. Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct? *

17. Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or healthcare facility of any military agency? *

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

19. 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? *

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

21. Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation? *

22. Within the last 10 years, did you have to respond an email from the Dental Board?*

23. Within the last 10 years, did you have to respond to a letter from the Dental Board? *

24. Within the last 10 years, did you have to call your Malpractice Insurance to help you?*

25. Have you ever received a DUI violation?*

Current copy of Certificate if board certified (if available)

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Explanation for any board violations (if available)

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Explanation for any judgments that you have been involved with in the past 5 years (if available)

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Dental Office

Dental Office Name for Credentialing *

Office Tax ID *

Thank you

New Doctor Credentialing Form

DEA License