Step 1a: Credentialing Application

  • Credentialing Application

  • Please complete the following forms. Once approved, we will email you a copy of your agreement and other information you might need.

    Disclaimer: This application will become part of your “Provider Agreement.”

  • Applicant Information

  • Gender*
  • Birth Date*
     / /
  • Format: (000) 000-0000.
  • Race/Ethnicity (optional)

  • Professional (Malpractice) Liability Carrier

  • Is your Malpractice Carrier limit at least 1M/3M?*

  • In order to continue with the Acu-Care Network you must have Malpractice Carrier insurance with a limit of 1M/3M.

  • Malpractice carrier limit*
  • Start Date*
     - -
  • End Date*
     - -

  • Please Update Your Policy to expire at least 60 days from today.

  • Office Liability Carrier or Premesis Liability Carrier

  • Is your General Liability carrier limits at least 1M/2M?*

  • In order to continue with the Acu-Care Network you must have General Liability Carrier insurance with a limit of 1M/2M.

  • General Liability carrier limit*
  • Start Date*
     - -
  • End Date*
     - -

  • Please Update Your Policy to expire at least 60 days from today.

  • Education

  • Degree:*
  • Are you a Licensed Acupuncturist with a L.Ac?*

  • In order to continue with the Acu-Care Network you must be a Licensed Acupuncturist with a L.Ac

  • Board Certification

  • Work History

  • Attestation Questions

  • Any current or present action or charges against you in the past 5 years? *
  • History of Loss or limitation: Has your Acupuncture License ever been revoked, suspended or subject to probation or disciplinary actions since your initial licensure? *
  • History of felony convictions: Have you ever been convicted of a felony? *
  • Has your Malpractice coverage ever been denied? *
  • Do you have any reasons which causes the inability to perform the essential functions of the position?*
  • Do you have any current, present, or past illegal drug use or alcohol or substance dependency that would interfere or affect your ability to practice medicine or perform essential functions in a competent, ethical and professional manner within the past two years?*
  • Do you have any current or present mental condition that impairs your judgement or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner? *

  • Who Referred You to Acu-care

  • How did you find us?*
  • Current Date*
     / /

  • Clinic Information

    • Clinic Information: Clinic 1 

    • Clinic #1

    • Your Status is:*
    • Is Clinic Mailing Address same as Home Address?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • In order to continue with the Acu-Care Network your clinic email address must be different from your personal email address

    • Rows
    • Clinic Information: Clinic 2 

    • Clinic #2

    • Your Status is:*
    • Is Clinic Mailing Address same as Home Address?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • In order to continue with the Acu-Care Network your clinic email address must be different from your personal email address

    • Rows
    • Location 3 Section 

    • Location 3

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Additional Email Type
    • Location 4 Section 

    • Location 4

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Additional Email Type
    • Location 5 Section 

    • Location 5

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Additional Email Type
    • End of Clinic Section 

  • Hiv/Aids Specialist Designation

    This legislation requires standing referrals to HIV/AIDS specialists for patients who need continued care for their HIV/AIDS.

    The Department of Managed Health Care (DMHC) recently defined an HIV/AIDS specialist under Regulation LS - 34 -01.

    In order to comply with this regulation, we need to identify appropriately qualified specialists within our network who meet the definition of an HIV/AIDS specialist.

    We will use your information for internal referral procedures and for publication listing in the Provider Directory.

    As always, if information about your practice changes, please notify us promptly.

  • Please select HIV/Aids Specialist Designation*

  • In the immediately preceding 12 months, I have clinically managed medical care to a minimum of 25 patients who are infected with HIV; AND

    1. In the immediately preceding 12 months, I successfully completed a minimum of 15 hours of category 1 continuing medical education in the prevention of HIV infection, combined with diagnosis, treatment or both of HIV-infected patients, including a minimum of 5 hours related to antiretroviral therapy per year; OR
    1. In the immediately preceding 12 months, I have obtained board certification or re-certification in the field of Infectious Disease from a member board of the American Board of Medical Specialties; OR
    2. In the immediately preceding 12 months, I have successfully completed a minimum of 30 hours of category 1 continuing medical education in the prevention of HIV infection, combined with diagnosis, treatment or both, of HIV-infected patients; OR
    3. In the immediately preceding 12 months, I have successfully completed a minimum of 15 hours of category 1 continuing medical education in the prevention of HIV infection, combined with diagnosis, treatment or both, of HIV-infected patients Medicine and successfully completed the HIV Medicine Competency Maintenance Examination administered by the American Academy of HIV Medicine.

  • Non-Discrimination

    Acu-Care is committed to ensuring equal opportunity and fairness in all aspects of its credentialing and contracting processes. We do not discriminate against any applicant or provider on the basis of race, color, religion, national origin, ethnicity, age, sex, sexual orientation, gender identity or expression, marital status, disability, genetic information, veteran status, or any other protected characteristic under applicable federal or state laws.

    Additionally, Acu-Care does not discriminate against licensed providers solely due to a civil judgment, criminal conviction, or professional disciplinary action in another state if such action is based only on the application of that state’s law that interferes with a person’s right to receive care that would be lawful if provided in California.

    By submitting this application, you acknowledge that you have read and understand this non-discrimination policy.

  • Attestation

    I hereby attest that the information I have provided in this application is current, correct and complete to the best of my knowledge and belief and in good faith. I understand that material omissions or misrepresentations may result in the denial of my application. 

  • Date*
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