Oklahoma Credentialing Application

Oklahoma Credentialing Application

Section 2 of 14: Directory Information
Credentialing Correspondence:
Mailing Address for all Credentialing Correspondence:*

Street Address

Suite Number

CityState

Zip Code
Phone Number for all Credentialing Correspondence:*
Please enter a valid phone number.
Fax Number for all Credentialing Correspondence:*
Please enter a valid phone number.
Emergency/Pager Number for all Credentialing Correspondence:*
Please enter a valid phone number.
Answering Service Number for all Credentialing Correspondence:*
Please enter a valid phone number.
Email for all Credentialing Correspondence:*
example@example.com
Contact Person For Credentialing Correspondence:*

First NameLast Name
Office Information:
Office Street Address:*

Street Address

Suite Number

CityState

Zip Code
Office Phone Number:*
Please enter a valid phone number.
Office Fax Number:*
Please enter a valid phone number.
Office Emergency/Pager Number:*
Please enter a valid phone number.
Answering Service Number:*
Please enter a valid phone number.
Office Email:*
example@example.com
Is the information above the same for mailing address?*

YesNo
Office Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Office Mailing Phone Number:*
Please enter a valid phone number.
Office Mailing Fax Number:*
Please enter a valid phone number.
Office Mailing Emergency/Pager Number:*
Please enter a valid phone number.
Office Mailing Answering Service Number:*
Please enter a valid phone number.
Office Mailing Email:*
example@example.com
Is the information above the same for billing address?*

YesNo
Billing Address:*

Street Address

Suite Number

CityState

Zip Code
Billing Phone Number:*
Please enter a valid phone number.
Billing Fax Number:*
Please enter a valid phone number.
Billing Emergency/Pager Number:*
Please enter a valid phone number.
Billing Answering Service Number:*
Please enter a valid phone number.
Billing Email:*
example@example.com
Is the information above the same for claims payment address?*

YesNo
Claims Payment Address:*

Street Address

Suite Number

CityState

Zip Code
Claims Payment Phone Number:*
Please enter a valid phone number.
Claims Payment Fax Number:*
Please enter a valid phone number.
Claims Payment Emergency/Pager Number:*
Please enter a valid phone number.
Claims Payment Answering Service Number:*
Please enter a valid phone number.
Claims Payment Email:*
example@example.com
Make Checks Payable To:*

Oklahoma Credentialing Application

Section 4 of 14: Education
Medical/Dental/Graduate Professional Schools

List all, completed or not.
Name of Institution:*
Degree Awarded:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Graduation Date:*

MonthDayYear
Date
Do you have another Institution to enter?*

YesNo
Name of Institution:*
Degree Awarded:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Graduation Date:*

MonthDayYear
Date
Do you have another Institution to enter?*

YesNo
Name of Institution:*
Degree Awarded:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Graduation Date:*

MonthDayYear
Date

Oklahoma Credentialing Application

Section 6 of 14: Academic Appointments
Do you have academic appointments to enter?

YesNo
Academic Appointments

List all, past and present
Name of Institution:*
Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Position/Rank:*
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Do you have another academic appointment to enter?*

YesNo
Name of Institution:*
Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Position/Rank:*
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Do you have another academic appointment to enter?*

YesNo
Name of Institution:*
Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Position/Rank:*
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date

Oklahoma Credentialing Application

Section 8 of 14: Other Professional Work History
Other Professional Work History

List, chronologically, all professional work history (i.e. clinics, partnerships, solo/group practices, employment). Include secondary agencies or clinics such as public health and family planning where you perform duties. Account for all time gaps of thirty (30) days or more.
Name of Facility:*
Nature of Affiliation:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Reason for Discontinuance:*
Do you have more work history to enter?*

YesNo
Name of Facility:*
Nature of Affiliation:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Reason for Discontinuance:*
Do you have more work history to enter?*

YesNo
Name of Facility:*
Nature of Affiliation:*
Mailing Address:*

Street Address

Suite Number

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Reason for Discontinuance:*
Please upload your CV:*

Cancelof
Did you serve in the US Military/Public Health Service?*

YesNo
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Location:*
Branch of Service:*
Do you have another US Military/Public Health Service to enter?*

YesNo
Date From:*

MonthDayYear
Date
Date To:*

MonthDayYear
Date
Location:*
Branch of Service:*

Oklahoma Credentialing Application

Section 9 of 14: Professional Licenses
Professional Licenses:

List all pending, current, and past professional licenses, registrations, and certifications to practice in your field. Include states where you have ever applied to practice. Examples of “type” of license are MD, DO, DDS, PA, DC, CRNA, MSW, etc.
State: (This first entry must be your Oklahoma License)*
Type:*
Number:*
Original Date of Issue:*

MonthDayYear
Date
Expiration Date:*

MonthDayYear
Date
Do you have another license to enter?*

YesNo
State:*
Type:*
Number:*
Original Date of Issue:*

MonthDayYear
Date
Expiration Date:*

MonthDayYear
Date
Do you have another license to enter?*

YesNo
State:*
Type:*
Number:*
Original Date of Issue:*

MonthDayYear
Date
Expiration Date:*

MonthDayYear
Date
Do you have another license to enter?*

YesNo
State:*
Type:*
Number:*
Original Date of Issue:*

MonthDayYear
Date
Expiration Date:*

MonthDayYear
Date
Do you have a USMLE/ECFMG Number to enter?*

YesNo
USMLE/ECFMG Number:*
Certification Date:*

MonthDayYear
Date

Oklahoma Credentialing Application

Section 12 of 14: Copies of Required Documents
Oklahoma Bureau of Narcotics and Dangerous Drugs Registration (BNDD):

Cancelof
Emergency Care Training Certificates (CPR, etc., if certified):

Cancelof
Photo Identification:*

Cancelof

Oklahoma Credentialing Application

Section 14 of 14: Additional Information
Please upload any information needed that was not able to be added on this application (if applicable):

Cancelof

Oklahoma Credentialing Application

Authorization and Consent for Release of Information
I hereby specifically authorize and consent for the following organizations to release to Med Advantage any and all records and information in your possession, which relates to my credentials as a physician and/or healthcare provider. The purpose of this authorization and consent to release is to permit Med Advantage to properly gather and verify my credentials to engage in the delivery healthcare or practice medicine.

State Licensing Organizations
License, Sanctions, State Requirements for Licensing, Education
Universities/Colleges/Graduate
Education and Training
Hospitals/Medical Facilities
Appointment Date/Privileges/Restrictions/Residency – Fellowship – Internship
Professional Liability Carrier
Certificate of Insurance that includes my professional liability insurance coverage history, which includes policy number, effective dates, limits of liability, and retroactive date.
Additional
The National Practitioner Data Bank, Federation of State Medical Boards, and Medicare/Medicaid for sanctions.

The purpose of this authorization and consent to release is to permit Med Advantage to properly gather and verify my credentials in accordance with the guidelines established by the National Committee on Quality Assurance (NCQA) and the Joint Commission Accreditation for Hospital Organizations (JCAHO). I hereby authorize and consent to Med Advantage providing any and all such information concerning my credentials to the healthcare organization, i.e., HMO, PPO, Hospital, etc., seeking to credential me for healthcare privileges. I hereby release any and all individuals, organizations and entities from any and all liability which might arise from their
furnishing such information and records to a third-party if such release is done at my request.

I agree to notify Med Advantage of any change in information.

I agree that this authorization and consent shall remain valid and in full force and effect until specifically withdrawn by me in writing.

I agree that a photocopy of this document will serve as a duplicate original.
Name:*

First NameLast Name
State License Number:*
Date:*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Oklahoma Credentialing Application

Oklahoma Credentialing Application

Credentialing Correspondence:

Office Information:

Oklahoma Credentialing Application

Oklahoma Credentialing Application

Medical/Dental/Graduate Professional Schools

Oklahoma Credentialing Application

Internship/Residency/Fellowship/Preceptorship/Other

Oklahoma Credentialing Application

Academic Appointments

Oklahoma Credentialing Application

Health Care Affiliations:

Oklahoma Credentialing Application

Other Professional Work History

Oklahoma Credentialing Application

Professional Licenses:

Oklahoma Credentialing Application

Certifications and Registrations:

Subspecialty Certification and Added Qualifications:

Board Qualifications

Classifications:

Oklahoma Credentialing Application

Primary Office:

Does your office have the following:

List all independent licensed non-physicians working in this office:

Fluent Languages:

Office Hours:

Secondary Office:

Does your office have the following:

List all independent licensed non-physicians working in this office:

Fluent Languages:

Office Hours:

Oklahoma Credentialing Application

Oklahoma Credentialing Application

Attestation:

Oklahoma Credentialing Application

Oklahoma Credentialing Application