The Minnesota Uniform Credentialing Application is a standardized form designed for healthcare professionals seeking reappointment. This comprehensive application collects essential information regarding a physician, dentist, or allied health professional's qualifications, practice history, and affiliations. Completing this form accurately is crucial to ensure a smooth reappointment process, so don't delay—fill it out by clicking the button below.
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The Minnesota Uniform Credentialing Application form is an essential document for healthcare professionals seeking reappointment. Alongside this form, several other documents are commonly required to ensure a complete application. Below is a list of these documents, each described briefly to clarify their purpose.
Completing the Minnesota Uniform Credentialing Application and submitting the necessary supporting documents is vital for a smooth reappointment process. Ensure all documents are accurate and up-to-date to facilitate your application.
What is the purpose of the Minnesota Uniform Credentialing Application form?
The Minnesota Uniform Credentialing Application form is designed for healthcare professionals, including physicians, dentists, and allied health professionals, to apply for reappointment. This form collects essential information about the applicant's qualifications, practice history, and current affiliations. It ensures that all necessary details are provided for the credentialing process, which is vital for maintaining professional standards and ensuring patient safety.
What information do I need to provide when filling out the application?
Applicants must supply a range of personal and professional information. This includes your name as it appears on your state license, contact information, and a detailed account of your employment history since your last reappointment. You will also need to disclose any hospital affiliations, educational background, and specialty areas. It is crucial to ensure that all information is accurate, complete, and legible, as any discrepancies may delay the processing of your application.
Are there specific instructions for completing the application?
Yes, there are several key instructions to follow. First, ensure that the application is filled out completely and accurately, using black ink or electronic generation. Avoid abbreviations and provide full details for all requested information. All signatures and dates must be clearly legible. If additional space is needed, you can attach separate sheets and reference the relevant questions. Finally, make sure to answer all disclosure questions and sign the required attestation and authorization sections.
What should I do if I have gaps in my employment history?
If there are gaps in your employment history of more than three months since your last reappointment, you must explain these interruptions. Provide the dates of the gaps and a brief explanation for each. This might include reasons such as pursuing other professional activities, personal travel, or sabbaticals. Transparency is important, as it helps the credentialing committee understand your professional journey and ensures a thorough evaluation of your application.
Filling out the Minnesota Uniform Credentialing Application form can be a straightforward process, but there are common mistakes that applicants often make. Understanding these pitfalls can help ensure that the application is completed accurately and efficiently.
One frequent error is incomplete contact information. Applicants sometimes forget to provide a complete street address, phone number, or email address. This information is crucial for communication during the credentialing process. Missing or incorrect contact details can lead to delays or even rejection of the application.
Another common mistake is using abbreviations. The application specifically instructs applicants not to use abbreviations when filling out their information. Abbreviations can lead to confusion and misinterpretation of the information provided. It is best to write out all words fully to avoid any misunderstandings.
Additionally, applicants often fail to sign and date the required sections clearly. All signatures and dates must be legible, as unclear signatures can raise questions about the authenticity of the application. Ensuring that all required signatures are present and clearly written is essential for a smooth review process.
Many applicants also overlook the importance of answering all disclosure questions on pages 10 and 11. These questions are critical for assessing the applicant's background and qualifications. Providing explanations for any affirmative answers is necessary to give context and clarity to the application.
Another mistake involves failing to include additional sheets when necessary. If the space provided on the application is insufficient for a complete answer, applicants should attach additional sheets and reference the corresponding question. Neglecting to do so can result in incomplete submissions, which may hinder the application process.
Lastly, applicants sometimes forget to designate dates correctly. Dates should be formatted as month, day, and year. Incorrect date formats can cause confusion and may delay the processing of the application. It is important to double-check that all dates are presented in the correct format to avoid any issues.
The Minnesota Uniform Credentialing Application form shares similarities with the National Practitioner Data Bank (NPDB) self-query form. Both documents serve as essential tools for healthcare professionals seeking to verify their credentials. The NPDB self-query form allows practitioners to check their own data in the NPDB, ensuring that all information is accurate and up-to-date. Similarly, the Minnesota application requires detailed personal and professional information, enabling healthcare providers to present their qualifications for reappointment or credentialing purposes.
Another related document is the Federation of State Medical Boards (FSMB) Uniform Application for Physician State Licensure. This application is designed for physicians seeking licensure in multiple states. Like the Minnesota form, it gathers comprehensive information about a physician's education, training, and professional history. Both applications emphasize the importance of accuracy and completeness in the information provided to ensure proper evaluation by licensing authorities.
The American Medical Association (AMA) Physician's Credentialing Application also bears resemblance to the Minnesota form. This application is used by physicians to apply for hospital privileges and insurance panel participation. Both documents require detailed information about the applicant's education, work history, and professional affiliations, ensuring that healthcare providers meet the necessary standards for practice in their respective fields.
The Joint Commission's Credentialing Application is another document that aligns with the Minnesota Uniform Credentialing Application. This application is used by healthcare organizations to verify the qualifications of healthcare professionals. Similar to the Minnesota form, it collects extensive information regarding an applicant's training, experience, and any disciplinary actions, promoting a thorough evaluation process to maintain high standards of care.
The American Association of Nurse Practitioners (AANP) Credentialing Application is comparable as well. This application is specifically designed for nurse practitioners seeking credentialing with various healthcare organizations. Both the AANP and Minnesota applications require detailed personal and professional information, highlighting the importance of transparency and thoroughness in the credentialing process for all healthcare professionals.
Additionally, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) Credentialing Application shares similarities with the Minnesota form. This document is used by nurse anesthesia programs to assess the qualifications of applicants. Both applications emphasize the need for accurate and complete information about education, training, and clinical experience, ensuring that only qualified individuals enter the field.
The Credentialing Verification Organization (CVO) Application is another document that mirrors the Minnesota application. CVOs are used by healthcare facilities to verify the credentials of healthcare professionals. Like the Minnesota form, the CVO application collects comprehensive data about the applicant's professional background, ensuring a thorough review process that upholds the integrity of healthcare delivery.
For those looking to transition into homeschooling in California, it's crucial to understand the formalities involved, including the submission of the California Homeschool Letter of Intent. This document not only notifies the local school district of your intention to homeschool but also ensures adherence to state regulations, thus protecting your family's educational choice. For more details on how to complete this important form, visit homeschoolintent.com/editable-california-homeschool-letter-of-intent.
Finally, the American Osteopathic Association (AOA) Membership Application is similar to the Minnesota Uniform Credentialing Application. This application is used by osteopathic physicians seeking membership and includes sections for personal and professional information. Both documents aim to ensure that applicants meet the necessary qualifications and standards, supporting the overall goal of maintaining high-quality care in the healthcare system.
Minnesota Uniform Credentialing Application
Reappointment
Physician/Dentist/Allied Health Professional
Applicant Name (as shown on your state license):
___________________________________________________________________________________________________________
LastFirstMiddleSuffixTitle
CREDENTIALING CONTACT INFORMATION
Name
_________________________________________________________
Phone Number _______________________________
Address
Fax Number _______________________________
E-mail ______________________________________
This Box to be Completed by Allied Health Professionals Only
Profession/Title _______________________________________________________
Sponsoring/Collaborative Physician _______________________________________
(Must complete if PA-C or APRN)
Instructions
The reappointment application and attachments should be filled out completely and accurately and must be legible or electronically generated. If more space is needed than provided on the application, please attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. ALL SIGNATURES AND DATES MUST BE CLEARLY LEGIBLE.
Please verify that you have:
Provided complete street address, phone, fax and e-mail addresses wherever indicated, including education/training, past employment, hospital affiliations & references
Designate dates by month, day and year time frames
Answered all of the Disclosure Questions on Pages 11 and 12 and enclosed explanations for affirmative answers
Signed and dated the Attestation Signature and Date statement (Page 13)
Signed and dated the Authorization and Release (Page 14)
All Information Must Be Printed in Black Ink or Electronically Generated
Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022
Practitioner Name:
Last:
First:
Middle:
Practitioner NPI:
Practitioner Race and Ethnicity Information
Race and/or ethnicity (for health plan use only): (The following information is optional and may be used in provider directories to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members.)
Select one or more
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
categories:
Asian
White
Prefer not to say
Black or African American
Other:
Check here if you do not wish for your race and/or ethnicity to be displayed in provider directories:
If provided on the credentialing application, the health plan may utilize race and/or ethnicity information in provider directories or in internal resources to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members. Providing race and/or ethnicity information on the credentialing application is entirely optional and refusal to provide this information will NOT subject you to adverse treatment. This information will not be considered in making any decisions regarding your credentialing.
Personal Data
Name (as shown on your state license):
__________________________________________________________________________________________________________________
Last
First
Middle
Suffix
Title
All Former Aliases: _____________________________________ Spouse Name (optional): _____________________________
Date of Birth: ___________________________________
Gender:
Male
Female
Social Security Number: ___________________________________ NPl: _________________________________________
Current Home Address:
______________________________________________________________________________________________
Street
City/State/Country
Zip Code
Preferred Mailing Address: Office
Home
Practitioner’s Preferred E-mail address: ___________________________________
Cell Phone Number: ___________________________________ Home Phone Number: ___________________________________________
Do you speak a language other than English with sufficient fluency to treat patients who speak only that language? Yes No
If yes, specify languages: _____________________________________________________________________________________________
Primary or Pending Practice Location
Primary Practice Location/Clinic Name: __________________________________________________________________________________
Address: __________________________________________________________________________________________________________
StreetCity/State/CountryZip Code
Office Phone Number: ______________________________________ Fax Number: ______________________________________________
Federal Tax ID Number: ______________________________________ Type II NPI: _____________________________________________
E-mail Address: ____________________________________________________________________________________________________
Start Date (at this location): ___________________________________________________________
Practicing as: Primary Care
Specialist
Urgent Care
Locum Tenens
Moonlighting Resident
Hospitalist
Hospital Based only
Teaching/Research only
Other (specify) _______________________________________
Accepting new patients? Yes
No
Directory Suppress?
Yes
Primary Specialty in which care will be provided: __________________________________________________________________________
Sub Specialty (ies) in which care will be provided: _________________________________________________________________________
Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet):
_________________________________________________________________________________________________________________
Page 2 of 17
Additional Practice Location(s) – Since Last Reappointment Applicant Name:
Other Practice Name: ____________________________________________________ Phone Number: _____________________________
E-mail Address: __________________________________________ Fax Number: _______________________________________________
Federal Tax ID Number (if different from primary): _____________________________ Type II NPI: __________________________________
Credentialing Contact: ________________________________________________________ Phone Number: __________________________
Other (specify) ________________________________________
Primary Specialty in which care will be provided: ___________________________________________________________________________
Sub Specialty (ies) in which care will be provided: __________________________________________________________________________
Fellowship/Post-Graduate/Professional Training – Since your last reappointment
(Month, day and year required)
From: _______________
Institution Name: _____________________________________________________________________________
To:
_______________
Type of Program/Specialty: ____________________________________________________________________
Completed Training: Yes No If no, expected completion date: ___________________________________
If not successfully completed, explain: ____________________________________________________________
Program Director: ____________________________________________________________________________
Address: ___________________________________________________________________________________
Phone Number: ___________________________________ Fax Number: _______________________________
E-mail address: _____________________________________________________________________________
Professional and Academic/Faculty Affiliations - Since your last reappointment
From: ______________
Appointment Held/Position: _____________________________________________________________________
Phone Number: _____________________________________ Fax Number: _____________________________
Page 3 of 17
Chronological Employment/Practice History (include Military Service)
Applicant Name:
(Additional space is provided on the Chronological Employment/Practice History Addendum. You may make extra copies of page 16 for additional employments.)
Chronological listing [month/day/year] of employment/practice history since your last reappointment. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOCLOGY.
Organization Name: __________________________________________________________________________
To: _______________
Title/Position: _______________________________________________________________________________
Reason for Leaving: __________________________________________________________________________
Employment Contact Name: ____________________________
Clinic Still Open? Yes No
If no, attach sheet listing address and phone number of someone who can verify your time there.
Phone Number: ______________________________________ Fax Number: ____________________________
E-mail address: ______________________________________________________________________________
Check here if you have additional employment history on attached Chronological Employment/Practice History Addendum (page 16)
Time Gaps: Explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice - since your last reappointment (if additional space is required, you may make extra copies of page 16 for additional time gaps.)
Explain: ____________________________________________________________________________________
___________________________________________________________________________________________
Check here if you have additional time gap information on attached Chronological Employment/Practice History Addendum (page 16)
Page 4 of 17
Primary Hospital Affiliation
(pertinent to Primary or Pending Practice Location listed on page 2)
If no hospital admitting privileges, describe method/coverage for continuity of care. Please provide covering physician’s name, if applicable.
Facility Name: _______________________________________________________________________________
Type/category of privilege/affiliation (active, courtesy, etc.): ___________________________________________
Application Pending
Department Chairperson: ______________________________________________________________________
Admitting Privileges:
Yes No (If no, please complete box above)
Other Hospital Affiliations - Since your last reappointment (Additional space is provided on the Hospital Affiliation
Addendum. You may make extra copies of page 17 for additional affiliations.)
Facility Name: _________________________________________________________________________
______________
Former Facility Name (if applicable): ____________________________________________
Facility Still Open?
Yes No
Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
Check here if you have additional hospital affiliations on attached Hospital Affiliation Addendum (page 17)
Page 5 of 17
Specialty/Subspecialty Certification
(Additional space is provided on the Specialty and Licensure Addendum, page 17. You may make extra copies of page 17 or attach a separate sheet for additional Specialty and Licensure.)
Primary Specialty:
Board Name: _______________________________________________________________________________________________________
Board Specialty: ____________________________________________________________________________________________________
Certificate Number: _________________________________________ Original Certificate Date: ____________________________________
Expiration Date: ____________________________________________ Certificate Pending
Secondary Specialty:
Board Sub-specialty: _________________________________________________________________________________________________
Additional Specialty:
Check here if you have additional specialty on attached Specialty and Licensure Addendum (page 18)
If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.
Licensure - List all past, current and pending professional licenses.
(Additional space is provided on the Specialty and Licensure Addendum, page 18. You may make extra copies of page 18 or attach a separate sheet for additional Specialty and Licensure.)
License Type
State
License Number
Date Issued
Expiration Date
License Status
__________
________
_________________
Active Inactive Pending
Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 18)
Page 6 of 17
Drug Enforcement Administration Registration
NOTE: Address on DEA certificate must be in state where you will be practicing as applicable to this application.
DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________
Approved for all schedules? Yes No, please explain: ________________________________________________________
Approved for all schedules? Yes No, please explain _________________________________________________________
If you do not maintain a DEA certificate, please explain:
Not applicable to practice DEA certificate pending; date application submitted to DEA: ___________________________________
Other ______________________________________________________________________________________________________
State Controlled Substance Certification/Registration (If applicable - not applicable to MN, WI, ND).
Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________
Life Support Certification
Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)?
If Yes: Type of Certification
Expiration Date(s)
___________________________________________________________
Continuing Education Attestation
Please read the following attestation carefully before signing and dating the statement.
I hereby certify that I have a sufficient number of CE credits to meet the licensure requirements and attest that an appropriate percentage relate to my specialty. I understand that these credits may be audited by an individual facility based on their individual requirements.
All signatures and dates must be clearly legible or signed with a unique electronic identifier.
Signature: __________________________________________________________ Date: _________________________
Name: ______________________________________________________________________________________________
(please print or type)
Page 7 of 17
Liability Insurance
Insurance Carrier for Primary and Pending Practice Location (You may attach a separate sheet for additional Liability Insurance.)
Enclose a copy of professional liability insurance coverage (e.g., face sheet/verification of self-insurance) for primary practice location to include effective dates, insurance carrier, expiration date, coverage limits, and name of each provider covered. If additional space is required, attach a separate sheet.
Coverage dates:
Start:
Current Insurance Carrier Name: ___________________________________________________________
Expire:
Address: _______________________________________________________________________________
Phone Number: ________________________________ Fax Number: ______________________________
E-mail address: _________________________________________________________________________
Certificate Pending
Name in which policy issued: ______________________________________________________________
Policy number: _________________________________________________________________________
Amount of coverage (per occurrence): _______________________________________________________
Amount of coverage (per aggregate): ________________________________________________________
Insurance Carrier Name: _________________________________________________________________
Address: ______________________________________________________________________________
Phone Number: ________________________________ Fax Number: _____________________________
Page 8 of 17
Professional/Peer References
List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation of your work. A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) Limit to one (1) current office associate. Do not include your residency director, fellowship director, relatives, or pending partners. At least one reference should be in your specialty (and if possible from the same subspecialty). Provide current and complete addresses. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you.
Name: _______________________________________________________________ Title: ________________________________________
Facility Name: __________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________
Phone Number: ________________________________________________ Fax Number: _____________________________________
E-Mail Address: _________________________________________________________________________________________________
Immune Status Information for Reappointment – Please provide immunity status by completing the question below.
DATE OF LAST PPD/MANTOUX:
Results:
Signature:
Date:
Page 9 of 17