• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Primary Practice Location:

• Currently Practicing at this location?*
  YesNo
• Previous or Future Start Date:*
   /Month /DayYear

  Date
• Physician Group/Practice Name to Appear in directory (Do not abbreviate)::*
• Group/Corporate Name as it appears on W-9, if different from above (Do not abbreviate)::

• Primary Practice Address:

• Street Number:*
• Street Name:*
• Suite/Building Number:
• City:*
• State:*
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code:*
• Send general correspondence here?*
  YesNo
• Phone Number:*
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Office Email:*
  example@example.com
• Individual Tax ID:*
• Group Tax ID:*
• What is your primary tax ID?*
  Individual Tax IDGroup Tax ID
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Office Manager or Business Office Staff Contact:

• Full Name:*
  First NameMiddle InitialLast Name
• Phone Number:*
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Email:*
  example@example.com
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Billing Contact:

• Is billing contact and address the same as entered for primary practice location and office contact before?*
  YesNo
• Full Name:*
  First NameMiddle InitialLast Name

• Billing Address:

• Street Number:*
• Street Name:*
• Suite/Building Number:
• City:*
• State:*
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code:*
• Phone Number:*
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Billing Contact Email:*
  example@example.com
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Payment and Remittance:

• Do you have electronic billing capabilities?*
  YesNo
• Billing Department (If Hospital-Based):
• Checks Payable to:*
  Your "Check Payable To" information should be consistent with your W-9.
• Is payment and remittance information the same as entered for primary practice location and office contact before?*
  YesNo
• Full Name:*
  First NameMiddle InitialLast Name

• Billing Address:

• Street Number:*
• Street Name:*
• Suite/Building Number:
• City:*
• State:*
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code:*
• Phone Number:*
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Email:*
  example@example.com
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Office Hours:

• Monday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Monday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Tuesday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Tuesday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Wednesday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Wednesday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Thursday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Thursday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Friday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Friday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Saturday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Saturday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Sunday Open:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Sunday Close:
  Round to the nearest half-hour.
• A=AM and P=PM:
  Please Select A P
• Do you have 24/7 phone coverage?*
  YesNo
• Please select one since you answered yes above on 24/7 phone coverage?
  Answering service.Voicemail with instructions to call answering service.Voicemail with other instructions.
• After Hours Back Office Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Open Practice Status:

• Are you accepting new patients into this practice?*
  YesNo
• Are you accepting existing patients with change of payor?*
  YesNo
• Are you accepting new patients with physician referral?*
  YesNo
• Are you accepting all new patients?*
  YesNo
• Are you accepting new medicare patients?*
  YesNo
• Are you accepting new medicaid patients?*
  YesNo
• Does any question above vary by plan?*
  YesNo
• Please explain:
• Are there any practice limitations?*
  YesNo
• Are there gender limitations?
  Male OnlyFemal OnlyNone
• Age Limitations:
  Minimum Age:
• Age Limitations:
  Maximum Age:
• List other limitations:
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Mid-Level Practitioners:

• Do mid-level practitioners (Nurse Practitioners, Physician Assistants, Etc.) care for patients in your practice?*
  YesNo
• Practitioner Full Name:
  First NameMiddle InitialLast Name
• Practitioner Type (E.G., PA, CNP, NP):
• Practitioner License/Certificate Number:
• Practitioner State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Do you have another practitioner to enter?*
  YesNo
• Practitioner Full Name:
  First NameMiddle InitialLast Name
• Practitioner Type (E.G., PA, CNP, NP):
• Practitioner License/Certificate Number:
• Practitioner State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Do you have another practitioner to enter?*
  YesNo
• Practitioner Full Name:
  First NameMiddle InitialLast Name
• Practitioner Type (E.G., PA, CNP, NP):
• Practitioner License/Certificate Number:
• Practitioner State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Do you have another practitioner to enter?*
  YesNo
• Practitioner Full Name:
  First NameMiddle InitialLast Name
• Practitioner Type (E.G., PA, CNP, NP):
• Practitioner License/Certificate Number:
• Practitioner State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Do you have another practitioner to enter?*
  YesNo
• Practitioner Full Name:
  First NameMiddle InitialLast Name
• Practitioner Type (E.G., PA, CNP, NP):
• Practitioner License/Certificate Number:
• Practitioner State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Languages:

• Is there non-English languages spoken by office personnel?*
  YesNo
• Non-English Languages Spoken by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field language code 1:
• Language Code 1:
• Is there another non-English languages spoken by office personnel?*
  YesNo
• Non-English Languages Spoken by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field language code 2:
• Language Code 2:
• Is there another non-English languages spoken by office personnel?*
  YesNo
• Non-English Languages Spoken by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field language code 3:
• Language Code 3:
• Is there another non-English languages spoken by office personnel?*
  YesNo
• Non-English Languages Spoken by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field language code 4:
• Language Code 4:
• Is there another non-English languages spoken by office personnel?*
  YesNo
• Non-English Languages Spoken by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field language code 5:
• Language Code 5:
• Are there interpreters available?*
  YesNo
• Language Interpreted by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field interpreted language code 1:
• Language Interpreted Code 1:
• Is there another language interpreted by office personnel?*
  YesNo
• Language Interpreted by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field interpreted language code 2:
• Language Interpreted Code 2:
• Is there another language interpreted by office personnel?*
  YesNo
• Language Interpreted by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field interpreted language code 3:
• Language Interpreted Code 3:
• Is there another language interpreted by office personnel?*
  YesNo
• Language Interpreted by Office Personnel:
  Please Select Abkhazian Afan (Oromo) Afar Afrikaans Albanian Amharic Arabic Armenian Assamese Zerbaijani Bashkir Basque Bengali;Bangla Bhutani Bihari Bislama Breton Bulgarian Burmese Byelorussian Cambodian Catalan Chinese Corsican Croatian Czech Danish Dutch English Esperonto Estonian Faroese Fiji Finnish French Frisian Galican Georgian German Greek Greenlandic Guarani Gujarati Hausa Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Interlingue Inuktitut Inupiak Irish Italian Japanese Javanese Kannada Kashmiri Kazakh Kinyarwanda Kirghiz Kurundi Korean Kurdish Laothian Latin Latvian;Lettish Lingala Lithuanian Macedonian Malagasy Malay Malayalam Maltese Maori Marathi Moldavian Mongolian Nauru Nepali Norwegian Occitan Oriya Pashto;Pushto Persian Polish Portuguese Punjabi Quechua Rhaeto-Romance Romanian Russian Samoan Sangho Sanskrit Scot Serbian Serbo-Croatian Sesotho Setswana Shona Sindhi Singhalese Siswati Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Tsonga Turkish Turkmen Twi Uigur Ukrainian Urdu Uzbek Vietnamese Volapuk Welsh Wolof Xhosa Yiddish Yoruba Zerbaijani Zhuang Zulu
• Auto field interpreted language code 4:
• Language Interpreted Code 4:
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Accessibilities:

• Does this office meet ADA accessibility requirements?*
  YesNo
• Does this site offer handicapped access for the following?*

  Rows	Yes	No
  Building
  Parking
  Restroom

• Other Handicapped Access:
• Does this site offer other services for the disabled?*
  YesNo
• Please select Yes or No on services below:*

  Rows	Yes	No
  Text Telephony (TTY)
  American Sign Language
  Mental/Physical Impairment Services

• Other Disability Services:
• Is this site accessible by public transportation?*
  YesNo
• Please select Yes or No on services below:*

  Rows	Yes	No
  Bus
  Subway
  Regional Train

• Other Transportation Services:
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Services:

• Does this office provide laboratory services?
  YesNo
• If yes, provide accrediting/certifying program (E.G., CLIA, COLA, MLE):
• Does this office provide radiology services?
  YesNo
• If yes, provide x-ray certification type:
• Please select the other following services:

  Rows	Yes	No
  EKGS
  Drawing Blood
  Asthma Treatment
  Pulmonary Function Testing
  Allergy Injections
  Age Appropriate Immunizations
  Osteopathic Manipulation
  Physical Therapy
  Allergy Skin Testing
  Flexible Sigmoidoscopy
  IV Hydration/Treatment
  Care of Minor Lacerations
  Routine Office Gynecology (PELVIC/PAP)
  Tympanometry/Audiometry Screening
  Cardia Stress Test

• Is anesthesia administered in your office?
  YesNo
• If yes, class/category do you use:
• If yes, who administers it?
  First NameLast Name
• Type of Practice:*
  Solo PracticeSingle Specialty GroupMulti-Specialty Group
• Additional Office Procedures Provided (Including Surgical Procedures):
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Partners/Associates

• Do you have partners or associates at this practice?*
  YesNo
• Partner/Associate Full Name:
  First NameMiddle InitialLast Name
• Is Partner/Associate a covering colleague?
  Please Select Y N Y=Yes N=No
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 1:
• Specialty Code 1:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 1:
• Provider Type Code 1:
• Do you have another partner or associate at this practice?*
  YesNo
• Partner/Associate Full Name:
  First NameMiddle InitialLast Name
• Is Partner/Associate a covering colleague?
  Please Select Y N Y=Yes N=No
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 2:
• Specialty Code 2:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 2:
• Provider Type Code 2:
• Do you have another partner or associate at this practice?*
  YesNo
• Partner/Associate Full Name:
  First NameMiddle InitialLast Name
• Is Partner/Associate a covering colleague?
  Please Select Y N Y=Yes N=No
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 3:
• Specialty Code 3:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 3:
• Provider Type Code 3:
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• Tennessee Uniform Credentialing Form

  Section 4 of 8: Practice Location Information

• Covering Colleagues:

• Do you have covering colleagues that are NOT partners/associates at this practice?*
  YesNo
• Colleague Full Name:
  First NameMiddle InitialLast Name
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 4:
• Specialty Code 4:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 4:
• Provider Type Code 4:
• Do you have another covering colleagues that are NOT partners/associates at this practice?*
  YesNo
• Colleague Full Name:
  First NameMiddle InitialLast Name
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 5:
• Specialty Code 5:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 5:
• Provider Type Code 5:
• Do you have another covering colleagues that are NOT partners/associates at this practice?*
  YesNo
• Colleague Full Name:
  First NameMiddle InitialLast Name
• Please Select Specialty (If applicable):
  Please Select Dentist, Dental Public Health Dentist, Endodontics Dentist, General Practice Dentist, Oral and Maxillofacial Pathology Dentist, Oral and Maxillofacial Radiology Dentist, Oral and Maxillofacial Surgery Dentist, Orthodontics and Dentofacial Orthopedics Dentist, Pediatric Dentistry Dentist, Periodontics Dentist, Prosthodontics
• Auto field specialty code 6:
• Specialty Code 6:
• Please Select Provider Type:
  Please Select Medical Doctor (MD) Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Podiatric Medicine (DPM) Doctor of Chiropractic (DC) Osteopathic Doctor (DO) Acupuncturist Alcohol/Drug Counselor Audiologist Biofeedback Technician Certified Registered Nurse Anesthetist Christian Science Practitioner Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Dietician Licensed Practical Nurse Marriage/Family Therapist Massage Therapist Naturopath Neuropsychologist Midwife Nurse Midwife Nurse Practitioner Nutritionist Occupational Therapist Optician Optometrist Pharmacist Physical Therapist Physician Assistant Professional Counselor Registered Nurse Registered Nurse First Assistant Respiratory Therapist Speech Pathologist
• Auto field provider type code 6:
• Provider Type Code 6:
• Back

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• Tennessee Uniform Credentialing Form

  Section 5 of 8: Hospital Affiliations

• Admitting Arrangements:

• Do you have hospital privileges?*
  YesNo
• If you do not admit patients, what type of admitting arrangements do you have?

• Hospital Privileges:

  Primary Hospital
• Primary Hospital Name:
• Street Number:
• Street Name:
• Suite/Building Number:
• City:
• State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code:
• Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Department Name:
• Department Director Full Name:
  First NameMiddle InitialLast Name
• Affiliation Start Date:
  MM/YYYY
• Affiliation End Date:
  MM/YYYY
• Do you have full, unrestricted privileges?
  YesNo
• Are privileges temporary?
  YesNo
• Admitting Privilege Status:
  E.G. None, Full Unrestricted, provisional, temporary
• Of your total annual admissions, what percentage is to this hospital?
• Do you have another hospital to enter?*
  YesNo

• Hospital Privileges:

  Other Hospital
• Other Hospital Name:
• Street Number:
• Street Name:
• Suite/Building Number:
• City:
• State:
  Please Select AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code:
• Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
• Department Name:
• Department Director Full Name:
  First NameMiddle InitialLast Name
• Affiliation Start Date:
  MM/YYYY
• Affiliation End Date:
  MM/YYYY
• Do you have full, unrestricted privileges?
  YesNo
• Are privileges temporary?
  YesNo
• Admitting Privilege Status:
  E.G. None, Full Unrestricted, provisional, temporary
• Of your total annual admissions, what percentage is to this hospital?
• Please explain terminated affiliation:
  E.G. None, Full Unrestricted, provisional, temporary
• Continue to Section 6 & 7
• Should be Empty: