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 to 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? *
Provider Authorization Agreement
I,
authorize Credentialing Genie (CMO Pacific LLC) to act on my behalf for the purposes of insurance credentialing and payer enrollment. This authorization includes, but is not limited to:
- Accessing, updating, and maintaining my CAQH profile and any other payer-required credentialing databases.
- Preparing, signing, and submitting credentialing applications to selected insurance payers on my behalf.
- Communicating directly with insurance companies, credentialing departments, and payer representatives regarding my applications, updates, and supporting documentation.
- Using my professional information (including NPI, dental license, DEA, education, work history, malpractice coverage) as required for credentialing.
- Receiving, responding to, and managing all credentialing-related correspondence from payers.
- I acknowledge that I will receive communications from Credentialing Genie via text and email to help ensure my credentialing information remains accurate and up to date.
HIPAA Compliance: Credentialing Genie will protect the confidentiality, integrity, and security of my personal and professional information in full compliance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy laws. My information will only be used or disclosed as required to complete credentialing and enrollment with insurance payers.
E-Sign Consent: By typing my name below and checking the acknowledgment box, I agree that my electronic signature has the same legal force and effect as a handwritten signature under the U.S. E-Sign Act.
This authorization remains valid until credentialing services are completed or revoked in writing. I certify that the information I have provided is true, accurate, and complete to the best of my knowledge.
