Uniform Credentialing Application
Demographic and Personal Data
Name of Applicant
First Name
Middle Name
Last Name
Maiden
Date of birth
-
Month
-
Day
Year
Date
Place of Birth
Social Security #
Sex
Male
Female
Practice Type
Please Select
Specialist
Primary Care
Primary Specialty
Secondary Specialty
Identify Areas of Clinical Expertise
What population do you treat?
Name of Practice
Provide the following information for each state in which you are currently or were previously licensed to practice
Rows
State
Date of License
License #
Status
Expiration Date
State 1
Active
Inactive
Suspended
State 2
Active
Inactive
Suspended
State 3
Active
Inactive
Suspended
State 4
Active
Inactive
Suspended
If you are certified by a specialty board, indicate the name of board and date of certificate.
Rows
Name
Date Certified
Expiration Date
Primary Specialty Board
Secondary Specialty Board
Are you listed in the American Board of Medical specialists?
Yes
No
If you have applied to a specialty board for examination, give the name of board and the date of scheduled examination
Name
Date
-
Month
-
Day
Year
Date
If you have not applied to a specialty board, please explain
Education and Practice History
List work history since beginning of medical, dental or other professional school
Rows
Name
From
To
Current Practice
Previous Practice
Previous Practice
Previous Practice
Previous Practice
Previous Practice
Professional Information
Please check yes or no for the following questions.
Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under investigation by any licensing or regulatory agency?
Yes
No
Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason?
Yes
No
Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under the threat of an investigation or are any such actions pending?
Yes
No
Have you ever been sanctioned or suspended by Medicare or Medicaid?
Yes
No
To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners?
Yes
No
Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to conduct?
Yes
No
Has a professional liability claim been assessed against you in the past 5 years, or are there any professional liability cases pending against you?
Yes
No
Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage?
Yes
No
Have you ever practiced without liability coverage?
Yes
No
Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position?
Yes
No
Have your hospital or clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending?
Yes
No
Please explain any Yes answers, including dates and locations
Submit
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