MN Uniform Credentialing Application 2011 free printable template

Minnesota Uniform Credentialing Application Initial Physician/Dentist/Allied Health Professional Applicant Name Last First Middle Suffix Title CREDENTIALING CONTACT INFORMATION Name Address Phone Number Fax Number E-mail This Box to be Completed by Allied Health Professionals Only Profession/Title Sponsoring/Collaborative Physician If applicable Instructions The initial credentialing application and attachments should be typed legibly printed in black ink or electronically generated. If more...

How to fill out MN Uniform Credentialing Application

How to fill out MN Uniform Credentialing Application

1. Obtain the MN Uniform Credentialing Application form from the relevant state board or website.
2. Begin by filling out your personal information, including full name, address, phone number, and email.
3. Provide your Social Security number and date of birth as required.
4. Enter your professional credentials, including your education history, training, and licenses.
5. List your work history, including all relevant employment and volunteer experiences.
6. Complete the sections on malpractice history and criminal background checks as needed.
7. Review and sign the application to attest that all provided information is accurate.
8. Attach any additional documents or evidence requested by the application form, such as copies of licenses or transcripts.
9. Submit the completed application along with the required fees to the appropriate credentialing board.

Who needs MN Uniform Credentialing Application?

1. The MN Uniform Credentialing Application is needed by healthcare professionals and organizations seeking licensure or credentialing in the state of Minnesota, including but not limited to physicians, nurses, and other allied health practitioners.

• Who needs a Minnesota Uniform Credentialing Application?
• Is Minnesota Uniform Credentialing Application accompanied by other forms?
• • How do I fill out the initial Minnesota Credentialing Application?
  • Where do I send Minnesota Uniform Credentialing Application?

Who needs a Minnesota Uniform Credentialing Application?

Every person (working as physician, dentist, allied health professional) who wants to apply for hospital and health plan credentials should use this Uniform Credentialing Application. Providers and Clinic Administration will find details specific to their needs using this specific form and contact the submitter.

Is Minnesota Uniform Credentialing Application accompanied by other forms?

Current copies of the following documents must be submitted with the MN Credentialing Application. If a submitter’s application for DEA and/or malpractice insurance are pending, please forward application and send those documents as soon as possible.

• Drug Enforcement Administration Registration (if applicable);

• EC FMG certificate (if educated outside of US or Canada);

• Malpractice Litigation and Professional Complaints Form (if applicable);

• Malpractice liability insurance documentation;

• Curriculum Vitae;

• Allied Health Professionals: License/registration and/or certification (if applicable).

How do I fill out the initial Minnesota Credentialing Application?

In general, the following information should be provided in order to complete the form:

• Applicant’s personal information;

• Primary or Pending Practice Location;

• Billing Information;

• Education;

• Residency/Postgraduate/Professional Training;

• Employment History;

• Specialty/Subspecialty Certification;

• Drug Enforcement Administration Registration;

• Liability Insurance;

• Professional/Peer References;

• Life Support Certification;

The Disclosure Questionnaire for Initial Credentialing is to be answered as well.

The last step in completing the form is signing out the Notice of Applicant’s Rights and Attestation.

The Application Attestation Update block must be signed only if a previous completed application is being reviewed and updated.

Present and past affiliations beginning with most recent.

If more space is needed than provided on the application, please attach additional sheets and reference the questions being answered. You should mark all non-applicable sections with N/A. Do not use abbreviations when completing the application.

Where do I send Minnesota Uniform Credentialing Application?

Once completed and signed, this form should be directed to the appropriate institution.

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What is MN Uniform Credentialing Application?

The MN Uniform Credentialing Application is a standardized form used in Minnesota for health care providers to apply for credentials with various health systems, ensuring uniformity and efficiency in the credentialing process.

Who is required to file MN Uniform Credentialing Application?

Health care professionals such as physicians, nurses, and allied health providers who wish to practice in Minnesota and seek credentials from medical facilities or insurance companies are required to file the MN Uniform Credentialing Application.

How to fill out MN Uniform Credentialing Application?

To fill out the MN Uniform Credentialing Application, applicants should gather all necessary personal, educational, and professional documentation, complete each section of the form accurately, and ensure that all required attachments and verifications are included before submitting it to the appropriate credentialing body.

What is the purpose of MN Uniform Credentialing Application?

The purpose of the MN Uniform Credentialing Application is to streamline the credentialing process for health care providers, reduce redundancy, and facilitate the verification of credentials among different health care organizations.

What information must be reported on MN Uniform Credentialing Application?

The MN Uniform Credentialing Application requires reporting information including personal identification details, education, training, work history, licensure and certification details, malpractice history, disciplinary actions, and any criminal history.