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Residence Address
City
State
Zip Code
UPIN
Place of Birth
Secondary Office Address
Date of Birth
Residence Phone Number
Street Address & Suite #
City
State
Zip Code
Phone Number
Fax Number
Answering Service Number
Pager Number
Street Address & Suite #
City
State
Zip Code
Phone Number
Answering Service Number
Fax Number
Pager Number
Additional Office Address
Street Address & Suite #
Sex
Marital Status
Name of Spouse
Last Name
First Name
Middle Name
Maiden Name/Other Name by Which You Have Been Known
Social Security Number
Office Address (If maintaining more than one office , list each office and address)
If not currently at this address - expected starting date.
Primary Office Address
Preferred Mailing Address:
Start Date
Universal Physician Credentialing Application
Copyright 1998-2001 Stephen Scott & Associates, Inc.
IDENTIFYING INFORMATION
Additional Office Address - continued

Practice Information
Identifying Information Physicians Who Share Call If Outside Your Group
On Call Physician Name #1
Address
City
State
Zip Code
Daytime Phone Number
After Hours Number
On Call Physician Name #2
Address
City
State
Zip Code
Daytime Phone Number
After Hours Number
Group Name
Clinic Manager
Billing Address & Suite #
City
State
Zip Code
Phone Number
Fax Number
City
State
Zip Code
Phone Number
Fax Number
Answering Service Number
Pager Number
Primary Specialty
Subspecialty
Subspecialty
Premedical Education
College or University
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical Education
Is your practice limited to a speciality or subspecialty? If so, please indicate:
Limited Specialty
Other interests in practice, research, etc:
Total years in practice.
Medical School
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical School
Start Date
Stop Date
Graduation Date
College or University
Start Date
Stop Date
Graduation Date
Address
City
State
Zip Code
Degree
Medical Education - continued
Internship
Institution
Address
Post graduate education
List name and type (Internship, Residency, Fellowship, Preceptorship) of all postgraduate educational programs in chronological order with dates, location, chiefs of staff, and speciality. List first postgraduate program first. If there is a time gap, please explain on a separate sheet of paper and make reference to this section.
Residency
Start Date
Stop Date
Chief of Staff
City
State
Zip Code
Training Program
If currently in residency, expected date of completion:
City
State
Zip Code
Institution
Start Date
Stop Date
Chief of Staff
Address
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Address
City
State
Zip Code
Degree
Residency - continued
Fellowship
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Preceptorship
City
State
Zip Code
Training Program
Address
Start Date
Stop Date
Chief of Staff
Institution
Institution
Start Date
Stop Date
Chief of Staff
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Training Program
Preceptorship - continued
Additional Postgraduate Education (Both hospital & non-hospital based)(Attach copies of ALL postgradual certificates)
Armed Services / Public Health List all medical and surgical dates and locations. Attach copy of your DD214
Address
City
State
Zip Code
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Institution
Start Date
Stop Date
Chief of Staff
Address
City
State
Zip Code
Training Program
Military Branch
Type of Discharge
Start Date
End Date
Reserve Status
Rank at time of discharge
Public Health Institution
Start Date
Stop Date
Address
City
State
Zip Code
Public Health Institution
Start Date
Stop Date
Address
City
State
Zip Code
Armed Services / Public Health - continued
PROFESSIONAL PRACTICE
Chronological listing of medical practice since medical training, including office and clinic. Include nature of and principal associates (solo, partnership, group) including office address and inclusive dates. If additional space is required, attach sheet of paper and make reference to this section.
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
PROFESSIONAL PRACTICE - continued
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
Practice Type
Address
City
State
Zip Code
Start Date
End Date
Country
ACADEMIC APPOINTMENTS
Start Date
End Date
Country
Institution
Address
ACADEMIC APPOINTMENTS - continued
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
City
State
Zip Code
Institution
Address
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Title
Rank
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
ACADEMIC APPOINTMENTS - continued
INSTITUTIONAL APPOINTMENTS
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
INSTITUTIONAL APPOINTMENTS - continuedList in chronological order ALL past and present hospital and health care facility afflilitions since completition of post graduate education. This includes all hospitals, corporations, military assignements, or government agencies. Complete name and address must be included . If additional space is required please attach a seperate sheet of paper and make reference to this section.
Phone Number
Fax Number
Title
Rank
INSTITUTIONAL APPOINTMENTS - continued
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Institution
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
LICENSES, REGISTRATIONS MEDICAL/DENTAL (active & inactive)
List ALL states where you hold or have held a medical license. Attach copies of ALL current license. If additional space is required, please attach a seperate sheet and make reference to this section.
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
LICENSES, REGISTRATIONS MEDICAL/DENTAL- continued (active & inactive)
OTHER PROFESSIONAL LICENSES HELD
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Do you write prescriptions for controlled substances?
MEMBERSHIP IN PROFESSIONAL SOCIETIES
List all professional fellowships, memberships, and societies, past and present, including state and county medical societies with dates. If additional space is required, please attach a seperate sheet and make reference to this section.
OTHER PROFESSIONAL LICENSES HELD - continued
State Agency
Address
City
State
Zip Code
Start Date
End Date
Country
Phone Number
Fax Number
Are you a foreign medical graduate? If yes have you passed the FLEX or ECFMG exams?
Please attach a copy of your ECFMG Certificate
ECFMG Number
DRUG ENFORCEMENT ADMINISTRATION (attach copies)
Federal DEA Number
Current
State DEA Number
Current
Phone Number
Fax Number
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
MEMBERSHIP IN PROFESSIONAL SOCIETIES - continued
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
Professional Association
Address
City
State
Start Date
End Date
Phone Number
Fax Number
Zip Code
Professional Association
Address
City
State
Start Date
End Date
Phone Number
Fax Number
Zip Code
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
MEMBERSHIP IN PROFESSIONAL SOCIETIES - continued
HEALTH DELIVERY SYSTEMS
List all HMO's, PPO's, IPX's, etc to which you belong or to which you are making application. If additional space is required, please attach a seperate sheet and make reference to this section.
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
Professional Association
Address
City
State
Zip Code
Start Date
End Date
Phone Number
Fax Number
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
Health Plan
Product
Start Date
End Date
HEALTH DELIVERY SYSTEMS
STATUS OF LICENSES AND MEMBERSHIPS
Have any of the following ever been, or are any currently in the process of being denied, revoked, suspended, reduced, limited, placed on probation, not renewed, or voluntarily relinquished. (If yes provide a full explanation on a seperate sheet and make reference to this section.)
Select all that apply
LIABILITY INSURANCE (attach copy of certificate)
Select all that apply
If you selected any of the above, please provide details on a seperate sheet of paper and make reference to this section.
Give names, addresses and policy numbers of any other insurance carrier during that time on a seperate attached sheet.
Insurance Carrier/Agent
Policy Number
Amount of Coverage
Start Date
End Date
BOARD CERTIFICATIONS (attach copies of all certifications)
Certified By
Date Certified
Expiration Date
Present member in good standing?
Does this board require recertification?
If not certified, have you applied for certification examination?
If no, do you intend to apply for certification examination?
If not certified, are you eligible to apply for certification examination?
Have you ever taken and failed a certification examination?
Certified By
Date Certified
Expiration Date
Present member in good standing?
Does this board require recertification?
If not certified, have you applied for certification examination?
If no, do you intend to apply for certification examination?
If not certified, are you eligible to apply for certification examination?
Have you ever taken and failed a certification examination?
Certified By
Date Certified
Expiration Date
Present member in good standing?
Does this board require recertification?
If not certified, have you applied for certification examination?
If no, do you intend to apply for certification examination?
If not certified, are you eligible to apply for certification examination?
Have you ever taken and failed a certification examination?
PROFESSIONAL REFERENCES
Professional Reference
Address
City
State
Phone Number
Professional Reference
Address
City
State
Phone Number
Professional Reference
Address
City
State
Phone Number
Professional Reference
Address
City
State
Phone Number
Name a least four (4) peers who have direct knowledge of your current clinical abilities, ethical character, health status and professional relationships and who will provide specific written comments on these matters if requested. Their experience of your practice must be recent, WITHIN FIVE YEARS. IMPORTANT: Only one reference may be a current associate, and at least one must be within your subspeciality, if applicable, and please do not use persons listed elsewhere in this application. DO NOT LIST TRAINING DIRECTORS OR FELLOW TRAINEES>
Professional Reference
Address
City
State
Phone Number
Professional Reference
Address
City
State
Phone Number
ADDITIONAL INFORMATION - foreign languages
Language
Language fluently written
Language fluently spoken
How many credit hours of continuing medical education have you completed during the past TWO years?
How many category I hours?
Language
Language fluently written
Language fluently spoken
Are you trained in signing for the English language?
Are you trained in signing for any other language?
Do you have valid AMA Physician's Recognition Aware?
Expiration Date
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