The West Virginia Credentialing Form is a crucial document designed for healthcare practitioners seeking to establish their qualifications and credentials with various credentialing entities. This form requires detailed information about the practitioner, including their educational background, licenses, and professional experience. Completing this form accurately is essential for ensuring a smooth credentialing process, so be sure to fill it out thoroughly and attach any necessary documentation.
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The West Virginia Credentialing Form is a crucial document for healthcare practitioners seeking to establish their qualifications and professional standing within the state. This form requires practitioners to provide comprehensive information about their professional background, including personal details such as name, date of birth, and social security number, as well as specific credentials and licenses. Applicants must attach various supporting documents, which may include copies of state licenses from all 50 states, DEA registrations, and proof of professional liability insurance. The form also requests details about the practitioner's office practice, including location, services offered, and patient demographics. Additionally, practitioners are expected to disclose any business interests or financial relationships with medical entities. It is essential to complete every section thoroughly and legibly, as any omissions or inaccuracies can lead to complications in the credentialing process. Practitioners should also be aware that they are responsible for all information submitted, regardless of who prepared it. This form serves not only as a means of verification but also as a way to ensure that practitioners meet the necessary standards to provide quality care to patients in West Virginia.
State of West Virginia
Credentialing Form
Please complete each section thoroughly.
Attach additional sheets where necessary.
(Indicate clearly the practitioner name and section on each attachment)
Type or print clearly in black ink.
Sign and date the application.
Practitioner’s Name
Date
Social Security Number
Date of Birth
Credentialing Entity Name
YOU MUST INCLUDE THE FOLLOWING WITH THIS
COMPLETED APPLICATION
(Use this checklist as a guide)
Copy of ALL current State License(s): For purposes of this application, State License shall include licensure from all 50 states, the District of Columbia, and U.S. Territories.
Copy of current DEA Registration (if applicable)
Copy of current State Controlled Dangerous Substance (CDS) Certificate (if applicable)
Copy of current professional liability insurance policy face sheet, showing expiration dates, limits, and Practitioner’s name
Copy of Board Certification Certificate(s) (if applicable), or other National Certification Certificates Copy of certificate(s) or letter(s) certifying formal post-graduate training
Copy of Curriculum Vitae/Resume (Include work history)
(Not accepted as a substitute for completion of application.)
Copy of ECFMG Certificate (if applicable)
Copy of W-9 for verification of each tax identification number used (required for payers only)
Copy of Visa or work permit (if not a U.S. citizen)
Copies of CME/CEU session certificates (if required by Credentialing Entity)
Signature requirements per each entity
Professional Peer References (if required by Credentialing Entity)
CREDENTIALING ENTITIES MAY SUPPLEMENT THIS CHECKLIST OF REQUIRED ITEMS AS NEEDED TO MEET CREDENTIALING REQUIREMENTS.
12/02; 3/03; 11/03; 1/04; 5/04; 10/04
**Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 1
Responses must be legible. Any response, which cannot be completed in the space provided, may be included on supplementary sheets of paper and attached. DO NOT LEAVE ANY FIELDS BLANK. If an item is not applicable, indicate N/A. Please note you will be held responsible for all information or omissions in this application, regardless of whether such statements were prepared by you, an employee, agent or representative. For time gaps greater than three (3) months provide information in Section 11. After completion of the application, you may photocopy and then submit with a signed attestation to each entity to which you wish to apply.
Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment. (If more space is needed, please supply the information on a separate sheet and attach.)
1. Applicant Information
Last Name
First Name
Middle Name
Maiden Name
Suffix
(as shown on state license)
(e.g., Jr., Sr., etc.)
Degree (e.g., MD, DO, DDS,
Gender
Birth Date
Birthplace
DPM, PA-C, RN)
Male
Female
Other Name(s) Also Known By
Name(s)
Name:
Date Name Used
From:
To:
Area(s) of Specialty (please be specific and list any primary focus)
Specialty:
Sub-specialty:
Citizenship
Are you a US Citizen?
Yes
No
If no, what is your citizenship?
Please provide the following
If no, what is status of your Visa?
information if you are not a
If no, do you hold a permanent work permit?
US Citizen:
Type of Visa:
Expiration of Visa:
Social Security #
National Provider ID # (if
ECFMG # (if applicable,
ECFMG Certificate Date
available)
attach copy)
Current Home Address
City
State
Zip Code
Home Telephone
Is this # unlisted?
Home Fax
(
)
-
Language(s) Spoken (other than English)
**Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 2
State of West Virginia Credentialing Form: Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment. (If more space is needed, please supply the information on a separate sheet and attach.)
2. Office Practice Information
If you have more than one office site or more than one billing address or entity, please make a photocopy of this section before completing it and provide information for each site or billing entity (i.e., multiple tax identifiers), as needed. Indicate below whether the office is the primary or an additional site. (NOTE: Only one primary site should be designated.)
Primary Office Site # 1
Additional Office Site #
Group/Practice Name
Individual
Hospital Based
Partnership
Type of Practice
Teaching or Research
Group
Other (specify):
Corporation
Address (Building, Street, Suite #)
County
Telephone Number
Fax Number
Answering Service/After-Hours Number
Alternate Telephone Number
Cell Phone Number
Beeper/Pager Number
E-Mail Address
Long Range Beeper Number
Medicare Number
UPIN Number
Medicaid Number
Are you currently accepting new patients?
Have you closed your practice to any plans or programs?
By referral only
NA
If Yes, please list:
Handicap Accessible?
Public Transit Available?
Does the office have other services available for disabled?
If yes, list below what services are available
(TTY, ASI, Mental/physical impairments, etc.)
Office Manager’s Name
Nurse Manager’s Name
Credentialing Contact
N/A
Name
Phone #
Office Hours ______
Check if not applicable
Check if
practitioner is not available to see patient during hours indicated
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM
PM
Services Provided
(Please check below if these services are available)
Lab Services
On-Site
Reference Lab Name:
CLIA Number and Type of Certification:
Radiology Services
EKG
Sigmoidoscopy
Audiology Services
Treadmill
Other (Please list):
List any special diagnostic or treatment procedures performed in your office:
12/02; 3/03; 11/03; 1/04; 5/04; 10/04 **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq**
Page 3
Patient Population
Do you limit the age of patients you treat?
If yes, what ages do you treat?
Minimum:
Maximum:
Remittance/Billing Information
(NOTE: Must match box 33 on HCFA/CMS 1500)
Are all services payable to one practice or group
name/address?
Group/Practice Name (Check Payable To):
Billing Office Phone Number
Billing Manager’s Name
Tax ID Number (must match W-9)
Name affiliated with Tax ID Number (must match W-9)
Business Interests
Do you or your business entity own, operate,
have an interest in, or participate in any medical
If yes, provide details on separate sheet.
enterprise or business?
Do you have a financial relationship with a
hospital, clinical lab, nursing home, pharmacy,
radiology lab, emergency room, or any other
medical related organization?
Practice Classification
Primary Care Physician (Family Practitioners, Internists, or Pediatricians who deliver primary health care services) Specialist Physician (Physicians other than primary care physicians in their designated clinical practice)
Allied Health Professional (Licensed, certified, or registered non-physician Practitioners of direct patient care services) Dual Role (Serve as both a Primary Care Physician as well as a Specialist)
Directory Listing
Should this office be listed in the directory?
Should this office receive correspondence?
Please indicate, in preference order, how you wish to be listed in the directory.
Primary Specialty:
Secondary Specialty:
After-Hours Coverage
Do you provide 24-hour coverage?
Describe Coverage
Do you have an answering service/machine?
Is your answering service/machine available
at all times when you are not in the office?
List below other after-hours arrangements or special instructions to patients for after-hours care needs:
Page 4
Back-up Coverage
(Please list the name, specialty, and phone number of partner(s) or associate(s)
or physician(s) covering your practice in your absence.)
Specialty
Partner, Associate,
Phone Number
Or Covering
Admitting Service
Do you admit patients to the hospital under your own service?
If no, to whom do you admit?
Practitioner Extenders
Please check any of the following practitioner extender types and list
individual names who you either employ or utilize for direct patient care.
Physician’s Assistant:
Nurse Practitioner:
Nurse Midwife:
Workers’ Compensation Information
Do you accept Workers’ Compensation Patients?
a. Are staff trained in identification and care of patients with work-related
illness/injury and provide care/services with an active return to work
philosophy?
b. Modified or alternative duty is actively evaluated for each Workers’
Compensation claimant.
If yes, please provide the following information:
c. Office will accommodate urgent walk-ins (or non-urgent appointments within
48 hours) to treat injured or ill workers and facilitate their return to work, if
possible.
d. Staff are available and willing to provide compensation representatives
information regarding a claimant’s care.
Page 5
3. Medical/Professional Education:
(Attach copy of diploma. If international graduate, submit ECFMG Certificate.)
If additional space is needed, please
photocopy this page and attach. All time gaps greater than three (3) months must be accounted for in Section 11.
Name of School
Degree Received
Dates of Attendance (List Mo/Yr)
Street Address
Phone # (if known)
Fax # (if known)
Graduation Date
Country
Telephone # (if known)
4.
Professional Training - Internship/Residency/Fellowship/Preceptorship/Other
List all, completed or not. (Attach copies of all program certificates.)
All time gaps greater than three (3) months must be
accounted for in Section 11.
Training Institution
Program
Internship
Fellowship
Other:
Residency
Preceptorship
Type of Training/Specialty
Dates of Training (Mo/Yr)
Was program successfully completed?
If no, explain:
Your Program Director’s Name
Current Program Director’s Name (if known)
Page 6
5. State License(s): List all current and past professional licenses (Submit copy of current licenses)
License #
Issue Date
Expiration Date
Status
Is/was license
Reason License is/was
(Please check)
restricted?
Inactive or Restricted
Active
Inactive
Does the scope of your practice require the supervision of
another practitioner?
If Yes, please list name of each supervising practitioner:
Practitioner Name:
Page 7
6. Certifications/Registrations
Check here if entire section is not applicable to applicant.
Federal DEA Certificate
Not applicable
(Submit copy of current DEA Certificate)
Certificate #
Expiration
Unlimited?
State DEA or CDS Certificate(s)
(Submit copy of current State Controlled Dangerous Substance Certificates, if applicable)
Other Certificate(s)/Formal Training
(Please check below if currently certified. Submit copy(s))
Basic Life Support (BLS)
Advanced Cardiac Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Advanced Trauma Life Support (ATLS)
Neonatal Advanced Life Support (NALS)
Anesthesia Permit
Health Care Practitioner (Core C)
Neonatal Resuscitation Program (NRP)
Therapeutics Classification Number (Optometrists only)
Other (please list below or on a separate sheet and include descriptions):
7.Specialty Board Certification: Submit copies of board certifications and/or qualification confirmation letter.
Are you board certified?
(If yes, list below)
Certifying Board Name & Specialty
Initial Certification Date
Most Recent
Next Expiration
Recertification Date
If not certified, are you qualified to sit for the examination?
Failed to pass specialty board examination
How many times have you taken the exam but failed
to pass?
Last date(s) exam was taken:
___________
If not certified, please indicate your status in the certifying
Date(s) board examination was taken/retaken and date board
exam is scheduled, if applicable:
process:
Date(s) taken/retaken:
_______________________
Date scheduled, if applicable:
_________________
Not eligible to take specialty boards
Not planning to take specialty boards
Admissible with exam pending
Page 8
8.Professional Peer References
Please list three (3) professional peer references who have personal knowledge of your current clinical abilities, ethical character, health status, and ability to work cooperatively with others, and who will provide specific written comments on these and other relevant matters upon request. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. These individuals must have acquired the requisite knowledge through observation of your professional practice over a reasonable period of time. At least one reference must be from the same specialty area, not formerly, currently or about to become associated with you in practice. At least one must be from an individual who has had organizational responsibility in a medical setting (e.g., Department Chair, Medical Director). If your training was completed within the past three (3) years, you may list your Program Director(s) as a professional reference. If you have been out of training for more than three (3) years, it is important to name individuals who are more currently familiar with your professional practice. The individuals should not be related to you by family or financial association.
Reference Name 1
Title
Zip
Fax Number (if known)
Relationship:
(instructor, department chair, chief of staff, colleague, etc.)
Reference Name 2
Reference Name 3
Page 9
9.Hospital/Health Care Entity Affiliations (list current affiliation first)
List ALL health care facilities at which you currently have, or have had, privileges. Explain gaps greater than three (3) months in
Section 11.
Name of Current Primary Hospital Affiliation
Type of Hospital/Health Care Entity
(e.g., Hospital, Nursing Home, etc.)
Department/Service
Department Chair’s Name
Staff Status
# Admits/Month
Percent of time spent at facility
Restricted?
Dates of Affiliation (Mo/Yr)
If yes, explain:
Reason for leaving, if applicable
Name of Affiliation/Hospital/Healthcare Entity
Page 10
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