Independent Provider Credential Verification

INDEPENDENT PROVIDER CREDENTIALING VERIFICATION

Licensed Independent Providers include, but are not limited to, physicians, physician assistants, nurse practitioners, dentists, and nurses who see patients independently.

This form is appropriate for providers who work for Charlotte Community Health Clinic (CCHC) by contract, or who volunteer for the program outside their regular office practice.

Instructions:
1. Provider will complete this form.
2. Attach a photocopy of a valid government issued ID, your malpractice insurance policy and BCLS certification (if relevant, CPR certification is recommended but not required).
PROVIDER INFORMATION
Name
Other names (if applicable)
Telephone
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther/prefer not to disclose
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Is this a home or work address?

HomeWork
PROVIDER EDUCATION, LICENSE, & INSURANCE INFORMATION
Highest professional degree
Name of school
City and state of school
Year of graduation
Field of Licensure
Specialty
License Number
State
Last 4 of SSN:
DEA
Board certification
Date of expiration

MonthDayYear
Date
CPR training expiration date

MonthDayYear
Date
Name at graduation
City
Malpractice company
State
Zip
Telephone
Supervising physician's name (mid-level practitioners only)
Supervising physician address (mid-level practitioners only)
PLEASE ANSWER THE FOLLOWING QUESTIONS
Have your professional license or hospital / clinic privileges ever been revoked?

YesNo
Have you been the defendant in a malpractice suit in the past 5 years?

YesNo
Are you currently aware of any malpractice actions against you?

YesNo
Are you aware of any health or other conditions that would render you unable to render health services to migrant farmworkers?

YesNo
Are you participating in any programs that provides loan forgiveness?

YesNo
Please attach an explanation for any "yes" answers.
I RECOGNIZE THAT CCHC HAS THE FOLLOWING REQUIREMENTS:
1. Protect patient confidentiality.
2. Protect myself, other staff, and volunteers by using universal precautions and safely disposing of all sharp objects and hazardous wastes.
3. Utilize standard infection control procedures against disorders such as chickenpox, tuberculosis, rubella, and diarrheal illness.
4. Report infectious illness to the county health department according to state law.
5. Report all work related injuries and incidents to the program manager.
6. CCHC will confirm my training and education using primary sources. CCHC will confirm my DEA, my license on-line annually, and will query the National Practitioner Data Bank continuously. I give CCHC permission to contact any schools necessary to verify my degrees or certificates.
"I have answered these questions truthfully and to the best of my ability. I will immediately notify the program of any change in my professional licensure or any suspension of privileges."
Signature

Clear
Date

MonthDayYear
Date
Print Name
Site
We so appreciate and look forward to your participation at Charlotte Community Health Clinic as a healthcare provider!

Please attach your BCLS certificate and photocopy of a valid government issued photo ID.
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PROVIDER INFORMATION

PROVIDER EDUCATION, LICENSE, & INSURANCE INFORMATION