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.
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Drug Enforcement Administration Registration (if applicable);
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EC FMG certificate (if educated outside of US or Canada);
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Malpractice Litigation and Professional Complaints Form (if applicable);
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Malpractice liability insurance documentation;
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Curriculum Vitae;
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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:
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Applicant’s personal information;
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Primary or Pending Practice Location;
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Billing Information;
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Education;
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Residency/Postgraduate/Professional Training;
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Employment History;
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Specialty/Subspecialty Certification;
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Drug Enforcement Administration Registration;
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Liability Insurance;
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Professional/Peer References;
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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.
