Recredential: Application

Provider's Name*

First NameM.I.Last Name

California Acupuncture License Number*

Business Email*

Personal Email*

Clinic Phone Number*

Personal Cell Number*

Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Professional Status

All questions must be answered. 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 or preform essential tasks 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 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.

Provider's Signature*

(NOTE: Signature must be original. If Adobe Acrobat, the signature must be an original signature uploaded into Adobe)

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