Recredential: Application

Provider's Name*

First NameM.I.Last Name

California Acupuncture License Number*

Personal Email*

example@example.com

Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code

Clinic Phone Number*

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Personal Cell Number*

Professional Status

All “YES” or “PENDING” answers must be explained below.

1. Within the last 5 years, has your license been voluntarily or involuntarily surrendered, limited or restricted, suspended or revoked, or have you received a reprimand, fine or sanction?*

YesNoPending

1. If "Yes" or "Pending", please explain below*

2. Within the last 5 years, have your privileges or membership at any health care facility been limited as a result of disciplinary conditions, denied, placed on probationary status, suspended, revoked, sanctioned, or involuntarily relinquished?*

YesNoPending

2. If "Yes" or "Pending", please explain below*

3. Within the last 5 years, have you been subject to any investigation or any disciplinary proceedings by any regulatory board, government agency, certifying organization, professional society, or health plan?*

YesNoPending

3. If "Yes" or "Pending", please explain below*

4. Within the last 5 years, have you been convicted of any felony or misdemeanor (other than a traffic violation) or have such charges pending?*

YesNoPending

4. If "Yes" or "Pending", please explain below*

5. Within the last 2 years, have you had any claims, suits, or settlements?*

YesNoPending

5. If "Yes" or "Pending", please explain below*

6. Do you have any current, present, or past illegal drug use or alcohol dependency that would interfere or affect your ability to practice medicine within the past two years?*

YesNoPending

6. If "Yes" or "Pending", please explain below*

7. Do you have any current or present mental condition that would interfere or affect your ability to practice medicine?*

YesNoPending

7. If "Yes" or "Pending", please explain below*

8. Within the last 2 years, has your Malpractice coverage ever lapsed (periods of no coverage) or been denied?*

YesNoPending

8. If "Yes" or "Pending", please explain below*

9. Do you currently have a Professional Liability Insurance policy for at least 1M/3M and Office Liability Insurance Policy for at least 1M/2M?*

YesNo

9. If "No", please explain below*

Please Upload MALPRACTICE INSURANCE and OFFICE LIABILITY policy declarations pages.

Please Upload:

The Declaration page of your MALPRACTICE (Professional Liability) Insurance Policy.
o Please double check the expiration date of policy.
o The insurance limits must be at least 1 Million per Occurrence and 3 Million Aggregate

Malpractice Insurance Policy*

Please Upload:

The Declaration page of your Office Liability Insurance Policy.
o Please double check the expiration date of policy.
o The insurance limits must be at least 1 million per occurrence and 2 million Aggregate.

Office Liability Insurance Policy*

I certify that the above statements are current, correct, and complete.

Provider's Signature*

Date*

Date

ShowFee

LateFee

Annual Renewal Subscription Fee

Processing Fee

Thank you for your application. Please note that the processing fee is non-refundable, as it helps cover the administrative costs associated with reviewing your submission. We appreciate your understanding and are happy to assist you with any other questions.

Total Amount Due

Re-Credential*

Annual Renewal Subscription Fee Product Image

Annual Renewal Subscription FeeAnnually recurring fee. Please contact Acu-Care to cancel 30 days prior to renewal date

$415.00 for each year

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Re-credentialing Application

All “YES” or “PENDING” answers must be explained below.