Tennessee Uniform Credentialing Form
Section 6 of 8: Professional Liability Insurance Carrier
Carrier or Self-Insured Name:
*
Self-Insured:
*
Yes
No
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:
*
Original Effective Date:
*
/
Month
/
Day
Year
Date
Effective Date:
*
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Type of Coverage:
*
Individual
Shared
Do you have unlimited coverage with this insurance carrier?
*
Yes
No
Does this policy include tail coverage?
Yes
No
Amount of Coverage Per Occurrence:
Amount of Coverage Aggregate:
Policy Number:
*
Please upload your malpractice insurance policy:
*
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Choose a file
Cancel
of
Have you had this policy less than 10 years?
*
Yes
No
Previous Professional Liability Insurance Carrier
List other previous carrier(s) if current carrier is less than ten(10) years.
Carrier or Self-Insured Name:
Self-Insured:
Yes
No
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:
Original Effective Date:
/
Month
/
Day
Year
Date
Effective Date:
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Type of Coverage:
Individual
Shared
Do you have unlimited coverage with this insurance carrier?
Yes
No
Does this policy include tail coverage?
Yes
No
Amount of Coverage Per Occurrence:
Amount of Coverage Aggregate:
Policy Number:
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Tennessee Uniform Credentialing Form
Section 7 of 8: Work History and References
Military Duty:
Are you currently on active military duty or military reserve?
*
Yes
No
Work History:
Include a chronological work history for the past 10 years.
Would you like to upload your CV?
*
Yes
No
Please upload your CV:
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Choose a file
Cancel
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Practice/Employer Name:
Street Number:
Street Name:
Suite/Building Number:
City:
State:
Please Select
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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:
Country:
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (provisional)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
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France, Metropolitan
French Guiana
French Polynesia
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Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadaloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Fortuna Islands
Western Sahara (provisional)
Yemen
Yugoslavia
Zambia
Zimbabwe
Auto field for country code 1:
Country Code 1:
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Start Date:
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Date
End Date:
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Month
/
Day
Year
Date
Reason for Departure (If Applicable):
Do you have more work history to enter?
Yes
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Practice/Employer Name:
Street Number:
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Zip Code:
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (provisional)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadaloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Fortuna Islands
Western Sahara (provisional)
Yemen
Yugoslavia
Zambia
Zimbabwe
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Reason for Departure (If Applicable):
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (provisional)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadaloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Fortuna Islands
Western Sahara (provisional)
Yemen
Yugoslavia
Zambia
Zimbabwe
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Tennessee Uniform Credentialing Form
Section 7 of 8: Work History and References
Gaps in Professional/Work History:
Please explain any time periods or gaps in training or work history that have occurred since graduation from professional school and are longer than three months in duration or of a shorter duration if required by the organization for which you are being credentialed.
Have you had gaps in your work history?
*
Yes
No
Gap Start Date:
/
Month
/
Day
Year
Date
Gap End Date:
/
Month
/
Day
Year
Date
Please Explain Gap in Work History:
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Tennessee Uniform Credentialing Form
Section 7 of 8: Work History and References
Professional References:
Provide three professional references to whom you are not related or are not partners in your practice.
Professional Reference 1:
Provide three professional references to whom you are not related or are not partners in your practice.
Full Name:
*
First Name
Last Name
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 for provider type code 1:
Provider Type Code 1:
Street Number:
*
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*
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City:
*
State:
*
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AZ
CA
CO
CT
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DE
FL
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KY
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ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
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NJ
NM
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NC
ND
OH
OK
OR
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SD
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TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
*
Phone Number:
*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Professional Reference 2:
Provide three professional references to whom you are not related or are not partners in your practice.
Full Name:
*
First Name
Last Name
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 for provider type code 2:
Provider Type Code 2:
Street Number:
*
Street Name:
*
Apt/Suite/Building Number:
City:
*
State:
*
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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
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SD
TN
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UT
VT
VA
WA
WV
WI
WY
Zip Code:
*
Phone Number:
*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Professional Reference 3:
Provide three professional references to whom you are not related or are not partners in your practice.
Full Name:
*
First Name
Last Name
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 for provider type code 3:
Provider Type Code 3:
Street Number:
*
Street Name:
*
Apt/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:
*
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Fax Number:
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Continue to Section 8
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