Dentist Credentialing Information Form

Dentist Credentialing Form
AFFIDAVIT OF SUBMITTED INFORMATION
DOCUMENTS & CREDENTIALS
____ CV with 5 years contiguous work history without gaps with month/ year format*

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____ Current copy of malpractice insurance *

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____ Current copy of state dental license (required) *

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____ Current copy of DEA license (required) *

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____ Current copy of Diploma (required)*

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____ W9

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____ 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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Credentialing Information
Dentist NPI Number:*
Do you have an AHCCCS provider ID Number?*
If YES, please list
AHCCCS ID#
Do you have a CAQH Number?*
CAQH Number:*
CAQH #
CAQH Username*
CAQH Password*
Do you have a CAQH username & password?*
Have you ever applied for a National Credentialing ID number?*
Do you have a Medicare ID Provider Number?*
If YES, please list
Medicare Provider #
If YES, please list
I hereby certify that all personnel information and miscellaneous documents that I provided is true and accurate to the best of my knowledge. This includes, but is not limited to, the following documents:

. Resume

. Certificates

. Credentials

. Diplomas

. Personal identification cards
I understand and agree to the above statement
Signature*
____ Dentist Digital Signature and Initial (photo of your Signature and Initial) *

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Personal Information
Dental Office Name*
Full Name*

First NameMiddle NameLast Name
Is there any other name(s) under which you have been known?
If so, please print:__________________________*
Doctor email address*
Doctor Cell Phone number*
MaleFemale
Date of Birth*

MonthDayYear
Date
Birthplace (Country, State or Province)*
Are you a U.S. citizen?*
If no, are you allowed to work in the U.S. ?*
When does your work visa expire?*

MonthDayYear
Date
Social Security Number:*
LICENSE INFORMATION
Dental License
Do you have a Dental License in other states?*
Other Current Dental License
Name of the State*

Street Address

Street Address Line 2

CityState

Zip Code
Other Current License Number:*
Issued Date*

MonthDayYear
Date
Dental License Expiration Date*

MonthDayYear
Date
EDUCATION
Undergraduate School
Undergraduate School Name:*
Undergraduate School's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Undergraduate School Start Date*

MonthDayYear
Date
Undergraduate School Completion Date*

MonthDayYear
Date
Undergraduate Degree Awarded
Dental School
Dental School Name*
Dental School's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental School's Start Date*

MonthDayYear
Date
Dental School's Completion Date*

MonthDayYear
Date
DMDDDSOther
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 a letter or email from the Dental Board? *
23. Within the last 10 years, did you have to call your Malpractice Insurance to help you?*
Please provide explanation for any "YES" answer from 1 to 23. You can also attach documents to support your explanations*
You may also attach additional documents to support your explanations

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Date

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Date
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Dentist Credentialing Form

Credentialing Information

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