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Content Overview

The Oregon Practitioner Recredentialing Application is a comprehensive document designed to facilitate the credentialing and recredentialing process for healthcare practitioners in Oregon. Established under House Bill 2144 in 1999, this application is developed by the Advisory Committee on Physician Credentialing Information (ACPCI) and is utilized by hospitals and health plans throughout the state. The form includes several key sections that practitioners must complete, such as personal information, specialty details, board certifications, and practice information. It is crucial for applicants to provide accurate and up-to-date information, as any modifications to the form's wording or format can invalidate the application. Additionally, the application requires supporting documents, including state professional licenses and certificates, to be submitted alongside the completed form. Practitioners should ensure that they sign and date specific pages of the application, as well as keep a copy for their records. The instructions emphasize the importance of clarity and completeness, guiding applicants through the process to ensure a smooth credentialing experience.

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  • Washington State Provider Credentialing Application: This form serves a similar function in Washington, gathering essential data about the provider’s qualifications, specialties, and practice history, along with required attachments.
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Preview - Oregon Practitioner Application Form

OREGON PRACTITIONER RECREDENTIALING

APPLICATION

APPLICATION

PROFESSIONAL LIABILITY ACTION DETAIL (ATTACHMENT A)

GLOSSARY OF TERMS AND ACRONYMS

Purpose: Established by 2UHJRQhouse bill 2144 (1999), the $ dvisory &ommittee on 3hysician &redentialing,nformation (ACPCI) develops the uniform applications used by hospitals and

health plans to credential and recredential PRACTITIONERS within the State of 2regon.

REVIEWED, AMENDED AND APPROVED

BY THE ADVISORY COMMITTEE ON PHYSICIAN CREDENTIALING INFORMATION (ACPCI)

5/1/12

Oregon Practitioner Recredentialing Application

Prior to completing this recredentialing application, please read and observe the following:

I.

INSTRUCTIONS

This form should be typed (using a different font than the form) or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered.

Modification to the wording or format of the Oregon Practitioner Recredentialing Application will invalidate the application.

Complete the application in its entirety. Keep an unsigned and undated copy of the application on file for future requests. When a request is placed, send a copy of the completed application to the health care related organization to which you are applying, making sure that all information is complete, current and accurate.

Please sign and date page 8, Attestation Questions and page 9, Authorization and Release of Information Form (and Attachment A, Professional Liability Action Detail, if applicable).

Each page of the application requires the applicant’s initials and the date on which the application was last reviewed.

Identify the health care related organization(s) to which this application is being submitted in the space provided below.

Attach copies of the documents requested each time the application is submitted.

If a section does not apply to you, please check the provided box at the top of the section.

Mail application to the requesting organization(s).

Current copies of the following documents must be submitted with this application:

State Professional License(s)

DEA Certificate or CSR Certificate

ECFMG (if applicable)

Face Sheet of Professional Liability Policy or Certificate

A curriculum vitae is optional and not an acceptable substitute.

I am applying to (please list: Hospital Staff, HMO, IPA):

 

 

for

 

 

(i.e., staff membership, network participation,

if applicable).

 

 

*Note: Please return completed application to the health care related organization to which you are applying, not to the State of Oregon.

Oregon Practitioner Recredentialing Application 5/1/12

Page 1 of 10

INITIALS:

DATE:

OREGON PRACTITIONER RECREDENTIALING APPLICATION

II.

PRACTITIONER INFORMATION

Please provide the practitioner’s full legal name.

Last name (include suffix; Jr., Sr., III):

 

First:

 

 

Middle:

 

 

 

Degree(s):

 

 

 

 

 

 

 

 

Is there any other name under which you have been known or have used since starting professional training?

Yes

 

No

Name(s) and year(s) used:

 

 

 

 

 

 

 

 

 

 

Home street address:

 

 

 

 

Home telephone number:

Mobile/alternate number:

 

 

 

 

 

 

(

)

 

 

(

)

 

 

 

 

 

 

Email address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

State:

 

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

Country:

 

Birth date (month/day/year):

 

 

 

Birth place:

 

 

 

 

/

/

 

 

 

 

 

 

 

Citizenship:

Social Security number:

 

 

 

Gender:

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

Immigrant visa number (if applicable):

Visa expiration date:

 

 

 

Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.SPECIALTY INFORMATION

This information may be included in directory listings.

Principal clinical specialty (For most current specialties list, see:

Do you want to be designated as a primary care practitioner (PCP)?

http://www.wpc-edi.com/codes):

 

 

Yes

No

 

 

Additional clinical practice specialties:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Category of professional activity, check all boxes that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical practice:

 

 

Other professional activities:

 

 

Full time

Part time

 

Administration

Teaching

Locum/temporary

Telemedicine

 

Research

Retired

Other (explain):

 

 

 

Other (explain):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV. BOARD CERTIFICATION/RECERTIFICATION

Does not apply

This section does not apply to licensure.

 

List all current and past certifications. Please attach additional sheets, if necessary.

 

 

 

Date

Expiration date

Name and address of issuing board:

Specialty:

certified/recertified

(if any)

 

 

month/year:

month/year:

 

 

 

 

 

 

 

 

 

 

 

 

If not currently board certified, describe your intent for certification, if any, and dates of previous testing and/or intended future testing for certification below. Please attach additional sheets, if necessary.

Oregon Practitioner Recredentialing Application 5/1/12

Page 2 of 10

INITIALS: ____________DATE: _____________________________

V.

OTHER CERTIFICATIONS

Please attach copy of certificate(s), if applicable.

Does not apply

Examples include: ACLS, BLS, ATLS, PALS, NRP, AANA, Fluoroscopy, Radiography, etc.

 

 

 

 

 

Type:

Number:

Month/year of certification:

Month/year of expiration:

 

 

 

 

Type:

Number:

Month/year of certification:

Month/year of expiration:

 

 

 

 

Type:

Number:

Month/year of certification:

Month/year of expiration:

 

 

 

 

Type:

Number:

Month/year of certification:

Month/year of expiration:

For additional certifications, please attach a separate sheet.

VI.

 

PRACTICE INFORMATION

 

 

 

 

 

 

Name of primary practice/affiliation or clinic:

 

 

 

Department name (if hospital based):

 

 

 

 

 

 

 

 

 

 

 

Primary clinical practice street address:

 

 

 

 

 

Effective date at location, month/year:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

County:

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

Primary office telephone number:

 

Primary office fax number:

 

Patient appointment telephone number:

(

)

Ext.:

(

 

)

 

 

(

)

 

Ext.:

Mailing/billing address (if different from above):

 

 

 

 

 

Attn:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office manager:

Office manager’s telephone number:

Office manager’s fax number:

 

 

 

 

 

 

(

 

)

Ext.:

(

)

 

 

Exchange/answering service number:

Pager number:

 

 

Office email address:

 

(

)

Ext.:

(

 

)

 

 

 

 

 

 

Recredentialing contact and address (if different

from above):

 

 

 

 

 

 

 

 

 

 

 

Recredentialing contact’s telephone number:

 

Recredentialing contact’s fax number:

Recredentialing contact’s email address:

(

)

Ext.:

 

(

)

 

 

 

 

 

 

Federal tax ID number or Social Security number, if

used for

Name affiliated with tax

ID number:

 

business purposes:

 

 

 

 

 

 

 

 

 

Name of primary practice/affiliation or clinic:

 

 

 

Department name (if hospital based):

 

 

 

 

 

 

 

 

 

Secondary clinical practice street address:

 

 

 

 

 

Effective date at location, month/year:

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

County:

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

Secondary office telephone number:

 

Secondary office fax number:

 

Patient appointment telephone number:

(

)

Ext.:

(

 

)

 

 

(

)

 

Ext.:

Mailing/billing address (if different from above):

 

 

 

 

 

Attn:

 

 

 

 

 

 

 

Office manager:

Office manager’s telephone number:

Office manager’s fax number:

 

 

 

 

 

 

(

 

)

Ext.:

(

)

 

 

Exchange/answering service number:

Pager number:

 

 

Office email address:

 

(

)

Ext.:

(

 

)

 

 

 

 

 

 

Recredentialing contact and address (if different

from above):

 

 

 

 

 

 

 

 

 

Recredentialing contact’s telephone number:

Recredentialing contact’s fax number:

Recredentialing contact’s email address:

(

)

Ext.:

(

 

)

 

 

 

 

 

 

Federal tax ID number or Social Security number,

if used for

Name affiliated with tax

ID number:

 

business purposes:

 

 

 

 

 

 

 

 

 

Please list other office locations with above information on a separate sheet.

 

 

 

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 3 of 10

INITIALS:

DATE:

VII.

PRACTICE CALL COVERAGE

 

 

Please provide the name and specialty of those practitioners who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

provide care for your patients when you are unavailable.

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

 

 

 

 

 

SPECIALTY:

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIII.

ADDITIONAL EDUCATION

If you have completed additional residencies,

Does not apply

 

 

internships or advanced specialized education within the past three (3) years, please provide the

 

 

following information. Please attach additional sheets, if necessary.

 

 

 

Complete name and street address of program:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

Phone number:

 

Fax

number, if available:

 

 

 

 

 

 

(

)

 

(

)

From month/year:

 

To month/year:

 

 

 

 

 

Month/year of completion:

 

 

 

 

 

 

 

Did you complete the program?

Yes

No

 

(If you did not complete the program, please explain on a separate sheet.)

 

 

 

 

 

 

 

 

 

 

Complete name and street address of program:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

Phone number:

 

Fax

number, if available:

 

 

 

 

 

 

(

)

 

(

)

From month/year:

 

To month/year:

 

 

 

 

 

Month/year of completion:

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you complete the program?

Yes

No

(If you did not complete the program, please explain on a separate sheet.)

IX. CONTINUING MEDICAL EDUCATION Please list activities for which

you have received CME credit(s) during the past two (2) years. Please attach a separate sheet, if needed.

Does not apply

Name:

Month/year attended:

Hours:

Name:

Month/year attended:

Hours:

Name:

Month/year attended:

Hours:

Name:

Month/year attended:

Hours:

Name:

Month/year attended:

Hours:

Name:

Month/year attended:

Hours:

 

 

 

X.HEALTH CARE LICENSURE, REGISTRATIONS, CERTIFICATES AND

ID NUMBERS Please attach additional sheets, if necessary.

Oregon license or registration number:

Type:

 

Month/day/year of expiration date:

 

 

 

 

 

Drug Enforcement Administration (DEA) registration

number (if applicable):

 

Month/day/year of expiration date:

 

 

 

 

Controlled substance registration (CSR) number (if applicable):

 

Month/day/year issued:

 

 

 

 

 

 

Individual NPI number:

 

Medicare number:

 

DMAP number:

 

 

 

 

 

 

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 4 of 10

INITIALS:

DATE:

XI. OTHER STATE HEALTH CARE LICENSES, REGISTRATIONS

AND CERTIFICATES Please attach additional sheets, if necessary

Does not apply

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

XII. HOSPITAL AND OTHER HEALTH CARE FACILITY AFFILIATIONS

Please list for the past three (3) years all health care institutions where you have and/or have had clinical privileges and/or staff membership. Include all (A) affiliations in the past three (3) years, and/or (B) applications in process (i.e., hospitals, surgery centers or any other health care related facility). If more space is needed, please attach additional sheets. Do not list residencies, internships or fellowships. Please list employment in Section XIII, Professional Practice/Work History.

A. AFFILIATIONS IN THE PAST THREE (3) YEARS

Facility name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

 

 

 

 

 

 

Status (e.g. active, courtesy, provisional, allied

 

Month/day/year of appointment:

 

health, etc.):

 

 

 

 

 

 

 

 

 

 

 

Facility name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

 

 

 

 

 

 

Status:

 

 

Month/day/year of appointment:

 

 

 

 

 

 

Facility name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

Status:

 

 

Month/day/year of appointment:

 

 

 

 

 

 

 

 

If you do not have hospital admitting privileges, check here:

Please explain on a separate sheet your plan for continuity of care for your patients who require admitting.

B. APPLICATIONS IN PROCESS

Does not apply

Facility name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

 

 

 

 

 

 

Status (e.g. active, courtesy, provisional, allied

 

Month/year of submission:

 

health, etc.):

 

 

 

 

 

 

 

 

 

 

 

Facility name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

 

 

 

 

 

 

Status:

 

 

Month /year of submission:

 

 

 

 

 

 

Facility Name:

Phone number:

Fax number, if available:

Complete address:

 

(

)

 

(

)

 

 

 

 

 

 

 

Status:

 

 

Month/year of submission:

 

 

 

 

 

 

 

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 5 of 10

INITIALS:

DATE:

XIII.

PROFESSIONAL PRACTICE/WORK HISTORY

A curriculum vitae is not sufficient.

 

A.

Please chronologically list and account for work, professional and practice history activities for the past three (3) years to

 

 

present, including military service. Please explain in section B any gaps greater than two (2) months.

 

 

Please attach additional sheets, if necessary.

 

 

 

Name of current practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month / Year:

To month/year:

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

 

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

 

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

 

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

Name of previous practice/employer:

 

 

 

Contact’s name:

 

 

 

 

 

 

Telephone number:

Fax number:

 

Complete address:

 

(

)

Ext.:

(

)

 

 

 

 

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

 

Contact’s email address, if available:

 

 

 

Professional liability carrier:

 

 

 

 

 

 

 

 

 

 

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 6 of 10

 

INITIALS:

DATE:

B. Please explain any gaps greater than two (2) months in the past three (3) years. Include activities and/or names and dates where applicable. Please attach additional sheets,

if necessary.

Does not apply

Activities and/or names:

From month/year:

To month/year:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XIV. PEER REFERENCES

Please list three (3) references, from peers who through recent observations, are directly familiar with your clinical skills and current competence. Do not include relatives. If possible, include at least one member from the Medical Staff of each facility at which you have privileges.

Name of reference:

 

 

 

Complete address, include department if applicable:

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

Professional relationship:

 

 

 

 

 

 

 

 

Telephone number:

 

Fax number:

Email address, if available:

(

)

Ext.:

(

)

 

Name of reference:

 

 

 

Complete address, include department if applicable:

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

Professional relationship:

 

 

 

 

 

 

 

 

Telephone number:

 

Fax number:

Email address, if available:

(

)

Ext.:

(

)

 

Name of reference:

 

 

 

Complete address, include department if applicable:

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

Professional relationship:

 

 

 

 

 

 

 

 

Telephone number:

 

Fax number:

Email address, if available:

(

)

Ext.:

(

)

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 7 of 10

INITIALS:

DATE:

XV.

PROFESSIONAL LIABILITY INSURANCE

Current insurance carrier/provider of professional liability coverage:

Policy number:

 

Type of coverage (check one):

 

 

 

 

 

 

 

Claims-made

Occurrence

Name of local contact:

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

Contact’s telephone number:

Fax number:

 

 

 

 

(

)

Ext.:

(

)

 

 

 

 

Per claim limit of liability:

 

Aggregate amount:

 

 

 

 

 

 

 

 

 

 

Month/day/year effective:

 

Month/day/year retroactive date,

if applicable:

Month/day/year of expiration:

 

 

 

 

 

 

 

 

 

 

Please list all previous professional liability carriers within the past three (3) years. Please attach additional sheets, if necessary.

Does not apply

Insurance carrier/provider of professional liability coverage:

Policy number:

 

Type of coverage (check one):

 

 

 

 

 

 

 

Claims-made

Occurrence

Name of local contact:

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

Contact’s telephone number:

Fax number:

 

 

 

 

(

)

Ext.:

(

)

 

 

 

 

Per claim limit of liability:

 

Aggregate amount:

 

 

 

 

 

 

 

 

 

 

 

Month/day/year effective:

 

Month/day/year retroactive date,

if applicable:

Month/day/year of expiration:

 

 

 

 

 

 

Insurance carrier/provider of professional liability coverage:

Policy number:

 

Type of coverage (check one):

 

 

 

 

 

 

 

Claims-made

Occurrence

Name of local contact:

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

Contact’s telephone number:

Fax number:

 

 

 

 

(

)

Ext.:

(

)

 

 

 

 

Per claim limit of liability:

 

Aggregate amount:

 

 

 

 

 

 

 

 

 

 

 

Month/day/year effective:

 

Month/day/year retroactive date,

if applicable:

Month/day/year of expiration:

 

 

 

 

 

 

Insurance carrier/provider of professional liability coverage:

Policy number:

 

Type of coverage (check one):

 

 

 

 

 

 

 

Claims-made

Occurrence

Name of local contact:

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

Contact’s telephone number:

Fax number:

 

 

 

 

(

)

Ext.:

(

)

 

 

 

 

Per claim limit of liability:

 

Aggregate amount:

 

 

 

 

 

 

 

 

 

 

 

Month/day/year effective:

 

Month/day/year retroactive date,

if applicable:

Month/day/year of expiration:

 

 

 

 

 

 

Insurance carrier/provider of professional liability coverage:

Policy number:

 

Type of coverage (check one):

 

 

 

 

 

 

 

Claims-made

Occurrence

Name of local contact:

 

 

 

Mailing address:

 

 

 

 

 

 

 

 

 

Contact’s telephone number:

Fax number:

 

 

 

 

(

)

Ext.:

(

)

 

 

 

 

Per claim limit of liability:

 

Aggregate amount:

 

 

 

 

 

 

 

 

 

 

Month/day/year effective:

 

Month/day/year retroactive date,

if applicable:

Month/day/year of expiration:

 

 

 

 

 

 

 

 

 

 

Oregon Practitioner Recredentialing Application 5/1/12

Page 8 of 10

INITIALS:

DATE:

XVI.

ATTESTATION QUESTIONS – This section to be completed by the Practitioner.

Modification to the wording or format of these Attestation Questions will invalidate the application.

Please answer the following questions “yes” or “no”. If your answer to any of the following questions is “yes”, please provide details and reasons, as specified in each question, on a separate sheet. Please sign and date each additional sheet.

A.In the last three (3) years has your license, certification, or registration to practice your profession, Drug Enforcement Administration (DEA) registration, or narcotic registration/certificate in any jurisdiction ever been denied, limited,

suspended, revoked, not renewed, voluntarily or involuntarily relinquished, or subject to stipulated or probationary

YES

NO

conditions, had a corrective action, or have you ever been fined or received a letter of reprimand or is any such action

 

 

pending or under review?

 

 

B.In the last three (3) years have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted

or excluded for any reasons, by Medicare, Medicaid, or any public program or is any such action pending or

YES

NO

under review?

 

 

C.In the last three (3) years have you ever been denied clinical privileges, membership, or contractual participation by

any health care related organization*, or have clinical privileges, membership, participation or employment at any such

YES

NO

organization ever been placed on probation, suspended, restricted, revoked, voluntarily or involuntarily relinquished or

 

 

not renewed, or is any such action pending or under review?

 

 

D.In the last three (3) years have you ever surrendered clinical privileges, accepted restrictions on privileges,

terminated contractual participation or employment, taken a leave of absence, committed to retraining, or resigned

YES

NO

from any health care related organization* while under investigation or potential review?

 

 

E.In the last three (3) years has an application for clinical privileges, appointment, membership, employment or

participation in any health care related organization* ever been withdrawn on your request prior to the organization’s

YES

NO

final action?

 

 

F.In the last three (3) years has your membership or fellowship in any local, county, state, regional, national, or

 

international professional organization ever been revoked, denied, limited, voluntarily or involuntarily relinquished or

YES

NO

 

not renewed, or is any such action pending or under review?

 

 

 

G.

In the past three (3) years, have you ever voluntarily or involuntarily left or been discharged from medical school or

YES

NO

 

subsequent training programs?

 

 

 

 

 

H.

In the last three (3) years have you ever had board certification revoked?

 

YES

NO

I.

In the last three (3) years have you ever been the subject of any reports to a state or federal data bank or state

YES

NO

 

licensing or disciplinary entity?

 

 

 

 

 

J.

In the last three (3) years have you ever been charged with a criminal violation

r ?

YES

NO

 

(felony or misdemeano )

 

 

K.

Do you presently use any illegal drugs?

 

YES

NO

L.Do you now have, or have you had, any physical condition, mental health condition, or chemical dependency condition

(alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice, with or without

YES

NO

reasonable accommodation, the privileges requested?

 

 

If reasonable accommodation is required, please specify the accommodation(s) required on a separate sheet.

 

 

M.Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner

agreement/hospital appointment, with or without reasonable accommodation, according to accepted standards of

YES

NO

professional performance?

 

 

N.In the last five (5) years have any professional liability claims or lawsuits ever been closed and/or filed against you?

If yes, please complete Attachment A, Professional Liability Action Detail, for each past or current claim

YES

NO

and/or lawsuit.

 

 

O.In the last three (3) years has your professional liability insurance ever been terminated, not renewed, restricted,

or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional

YES

NO

liability insurance?

 

 

*e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), physician hospital organization (PHO), medical society, professional association, health care faculty position or other health delivery entity or system

I certify the information in this entire application is complete, current, correct, and not misleading. I understand and acknowledge that any misstatements in, or omissions from this application will constitute cause for denial of my application or summary dismissal or termination of my clinical privileges, membership or practitioner participation agreement. A photocopy of this application, including this attestation, the authorization and release and any or all attachments has the same force and effect as the original. I have reviewed this information on the most recent date indicated below and it continues to be true and complete. While this application is being processed, I agree to update the information originally provided in this application should there be any change in the information.

I agree to provide continuous care for my patients, until the practitioner/patient relationship has been properly terminated by either party, or in accordance with contract provisions.

Signature:

Date:

Oregon Practitioner Recredentialing Application 5/1/12

Page 9 of 10

INITIALS:

DATE:

Key takeaways

Filling out the Oregon Practitioner Application form is an essential step for practitioners seeking credentialing or recredentialing in the state. Here are some key takeaways to ensure a smooth process:

  • Complete the Application Thoroughly: Every section of the application must be filled out completely. Incomplete applications may lead to delays or denials.
  • Use the Correct Format: The application should be typed or printed clearly in black or blue ink. Modifying the wording or format can invalidate the application.
  • Document Submission: Ensure that all required documents, such as state professional licenses and DEA certificates, are attached when submitting the application.
  • Initials and Dates Required: Each page of the application needs your initials and the date it was last reviewed. This is crucial for tracking the application’s status.
  • Health Care Organization Identification: Clearly identify the health care organization(s) to which you are applying. This helps streamline the processing of your application.
  • Sign and Date the Attestation: Remember to sign and date the attestation questions and the authorization form. This confirms your agreement to the information provided in the application.

By keeping these points in mind, practitioners can navigate the application process more effectively, ensuring all necessary information is provided accurately and promptly.

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File Details

Fact Name Description
Governing Law The Oregon Practitioner Recredentialing Application is governed by House Bill 2144, enacted in 1999.
Application Format The application must be typed or printed in black or blue ink. Modifications to the format will invalidate the application.
Required Documents Applicants must submit current copies of their state professional license, DEA certificate, and other relevant documents with the application.
Submission Instructions Completed applications should be sent directly to the health care organization, not to the State of Oregon.
Initials and Dates Each page of the application requires the applicant's initials and the date of the last review.
Attestation Requirement Applicants must sign and date specific pages, including the Attestation Questions and Authorization and Release of Information Form.

Documents used along the form

When applying for the Oregon Practitioner Recredentialing Application, several additional forms and documents may be required to ensure a comprehensive submission. These documents help verify qualifications, provide necessary background information, and facilitate the credentialing process. Below is a list of commonly associated documents.

  • State Professional License(s): This document confirms that the practitioner holds a valid license to practice in Oregon. It is essential for demonstrating compliance with state regulations.
  • Durable Power of Attorney Form: To ensure your healthcare and financial decisions are respected, consider preparing a Durable Power of Attorney form. For a convenient resource, visit Illinois PDF Forms.
  • DEA Certificate or CSR Certificate: This certificate is necessary for practitioners who prescribe controlled substances. It verifies that the practitioner is authorized to handle these medications legally.
  • ECFMG Certification (if applicable): For international medical graduates, this certification proves that they have met the educational standards set by the Educational Commission for Foreign Medical Graduates, allowing them to practice in the U.S.
  • Face Sheet of Professional Liability Policy or Certificate: This document provides evidence of malpractice insurance coverage, which is important for protecting both the practitioner and the patients they serve.
  • Curriculum Vitae (optional): While not mandatory, a CV can provide additional context about the practitioner’s education, experience, and professional achievements, enhancing their application.
  • Additional Sheets for Questions: If the application requires more space than provided for certain questions, extra sheets should be attached. These must reference the specific question being answered to maintain clarity.

Including these documents with the Oregon Practitioner Recredentialing Application is crucial for a smooth and efficient credentialing process. Ensure that all information is accurate and up-to-date to avoid any delays in your application review.