CREDENTIALING FORM

PERSONAL INFO
LAST NAME	FIRST NAME	DATE
ADDRESS
PHONE	EMAIL
SS#	Tax ID#	DL#

APPOINTMENT / REAPPOINTMENT
Application for appointment or reappointment, including authorization for release of information

PROFESSIONAL USE
AMA Profile
Verification of Board Certification
ECFMG Certification for graduates of international medical schools

EDUCATION
Medical School Verification
Date of Graduation
Post-graduate Education

LICENSES
LICENSE	VERIFICATION	EXPIRATION DATE
DEA	VERIFICATION	EXPIRATION DATE
DEA
LIFE SUPPORT	VERIFICATION	EXPIRATION DATE
BLS
ACLS
PALS
FLUOROSCOPY	VERIFICATION	EXPIRATION DATE
FLUOROSCOPY

MALPRACTICE
Insurance Verification
Expiration Date
Claims History

SANCTIONS
NPBD Check
OIG Check
FSMB Check

PRIVILEGING
Information on privileges can be granted as provider
OPPE Check
FPPE Check

OTHER
Peer References
Health information, including required vaccinations
Additional important information / comments

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