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In a landscape that increasingly demands both efficiency and accuracy in the healthcare credentialing process, the Minnesota Uniform Credentialing Application form stands out as a critical tool for physicians, dentists, and allied health professionals. Designed with a comprehensive structure, this form encompasses personal data, credentialing contact information, and specific sections for allied health professionals indicating the requirement of a sponsoring or collaborative physician for certain roles. The significance of filling out the form correctly cannot be overstated as it requires detailed information including employment practice history, any additional practice locations since the last reappointment, and a chronological account of professional training and education undertakings. Besides basic personal and contact information, the form delves into professional affiliations, hospital associations, and a narrative description of clinical practices, showcasing special interests if any. It underscores the necessity of providing complete and legible information, with instructions that guide applicants through the process of designating space for disclosure questions and emphasizing the importance of signatures where required. Since its inception in 2001 and through several revisions, the latest being in 2016, this document has adapted to meet the evolving needs of credentialing processes, making it a fundamental step for healthcare professionals aiming to validate their qualifications and ensure continuity in delivering high-quality care.

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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

No

 

 

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):

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 2 of 17

Additional Practice Location(s) – Since Last Reappointment Applicant Name:

Other Practice Name: ____________________________________________________ Phone Number: _____________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

E-mail Address: __________________________________________ Fax Number: _______________________________________________

Federal Tax ID Number (if different from primary): _____________________________ Type II NPI: __________________________________

Credentialing Contact: ________________________________________________________ Phone Number: __________________________

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

No

 

 

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: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ___________________________________ Fax Number: _______________________________

 

 

E-mail address: _____________________________________________________________________________

Professional and Academic/Faculty Affiliations - Since your last reappointment

 

 

 

 

 

 

(Month, day and year required)

 

 

 

From: ______________

Institution Name: _____________________________________________________________________________

To:

_______________

Appointment Held/Position: _____________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

Phone Number: _____________________________________ Fax Number: _____________________________

E-mail address: _____________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

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.

(Month, day and year required)

From: _______________

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.

Address: ___________________________________________________________________________________

 

Street

City/State/Country

Zip Code

 

Phone Number: ______________________________________ Fax Number: ____________________________

 

E-mail address: ______________________________________________________________________________

From: _______________

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.

Address: ___________________________________________________________________________________

 

Street

City/State/Country

Zip Code

 

Phone Number: ______________________________________ Fax Number: ____________________________

 

E-mail address: _____________________________________________________________________________

From: _______________

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.

Address: ___________________________________________________________________________________

StreetCity/State/CountryZip Code

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.)

(Month, day and year required)

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

Check here if you have additional time gap information on attached Chronological Employment/Practice History Addendum (page 16)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 4 of 17

Primary Hospital Affiliation

Applicant Name:

 

 

(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.

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

(Month, day and year required)

 

 

 

From: _______________

Facility Name: _______________________________________________________________________________

To:

_______________

Type/category of privilege/affiliation (active, courtesy, etc.): ___________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

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.)

 

 

 

(Month, day and year required)

 

 

 

From: _______________

Facility Name: _________________________________________________________________________

To:

______________

Former Facility Name (if applicable): ____________________________________________

 

Facility Still Open?

 

Yes No

 

 

 

 

 

 

Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

Admitting Privileges:

Yes No (If no, please complete box above)

 

 

 

From: _______________

Facility Name: _________________________________________________________________________

To:

______________

Former Facility Name (if applicable): ____________________________________________

 

Facility Still Open?

 

Yes No

 

 

 

 

 

 

Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

Admitting Privileges:

Yes No (If no, please complete box above)

 

 

 

Check here if you have additional hospital affiliations on attached Hospital Affiliation Addendum (page 17)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 5 of 17

Specialty/Subspecialty Certification

Applicant Name:

 

 

(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 Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

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

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 18)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 6 of 17

Drug Enforcement Administration Registration

Applicant Name:

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: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

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: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Life Support Certification

Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)?

Yes No

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)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 7 of 17

Liability Insurance

Applicant Name:

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:

(Month, day and year required)

 

 

 

Start:

_______________

Current Insurance Carrier Name: ___________________________________________________________

Expire:

_______________

Address: _______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

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): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ________________________________ Fax Number: _____________________________

 

 

E-mail address: _________________________________________________________________________

 

 

Name in which policy issued: ______________________________________________________________

 

 

Policy number: _________________________________________________________________________

 

 

Amount of coverage (per occurrence): _______________________________________________________

 

 

Amount of coverage (per aggregate): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

Phone Number: ________________________________ Fax Number: _____________________________

E-mail address: _________________________________________________________________________

Name in which policy issued: ______________________________________________________________

Policy number: _________________________________________________________________________

Amount of coverage (per occurrence): _______________________________________________________

Amount of coverage (per aggregate): ________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 8 of 17

Professional/Peer References

Applicant Name:

 

 

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: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

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:

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 9 of 17
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Document Attributes

Fact Detail
Application Purpose The form is used for the reappointment of physicians, dentists, and allied health professionals in Minnesota.
Information Required Applicants must provide personal data, credentialing contact information, practice locations, and a complete employment/practice history.
Signature Requirements All signatures and dates on the form must be clearly legible to be considered valid.
Governing Law The form is governed by Minnesota state laws regarding the credentialing and reappointment of healthcare professionals.

How to Fill Out Minnesota Uniform Credentialing Application

Filling out the Minnesota Uniform Credentialing Application form is an important step towards reappointing your position as a physician, dentist, or allied health professional. This process ensures that all relevant personal and professional information is up-to-date, facilitating your credential verification in an efficient manner. Carefully and accurately completing the application is crucial for a seamless reappointment process, so each step outlined below should be followed diligently.

  1. Enter your full name as it appears on your state license under "Applicant Name," including your last, first, middle name, suffix, and title.
  2. Fill in your Credentialing Contact Information, including the contact name, phone number, address, fax number, and email.
  3. If you are an Allied Health Professional, specify your profession/title and your sponsoring/collaborative physician in the designated box.
  4. Check off the tasks in the checklist on the first page to ensure all parts of the application will be completed. This includes confirming the inclusion of complete address and contact information, designating dates with precise timeframes, responding to all disclosure questions, and signing all necessary sections.
  5. Under Personal Data, include all former aliases, your spouse's name (optional), date of birth, gender, social security number, NPI, home address, preferred mailing address, and your contact information.
  6. Indicate if you speak any languages other than English with enough fluency to treat patients who speak only those languages, listing the languages if applicable.
  7. Detail your Primary or Pending Practice Location information, including the clinic name, address, contact numbers, and email. Also, provide specifics about your practice focus and whether you are accepting new patients.
  8. For Additional Practice Locations since your last reappointment, input the relevant details similar to what you provided for your primary practice location. Include information about the type of practice and specialties offered.
  9. List your Fellowship/Post-Graduate/Professional Training since your last reappointment, including the institution name, program type, and program director’s contact information. Clearly indicate if the training was completed.
  10. Under Professional and Academic/Faculty Affiliations, input your affiliations since your last reappointment, detailing the institution name, appointment held/position, and contact information.
  11. Complete the section on Chronological Employment/Practice History, providing an exhaustive list of your employment history since your last reappointment. Ensure to list all experiences, including military service and any significant gaps in practice, providing reasons for each.
  12. Detail your Primary Hospital Affiliation and Other Hospital Affiliations since your last reappointment. Include information about the facility name, type of privilege/affiliation, and contact details of the department chairperson.
  13. Review the Disclosure Questions on pages 10 and 11, answering each truthfully and providing explanations for any affirmative answers.
  14. Sign and date the Attestation Signature and Date statement on Page 12 and the Authorization and Release on Page 13. Remember, all signatures and dates must be clearly legible.

After completing these steps, ensure all information is printed in black ink or is electronically generated and double-check that no section has been left incomplete. Submitting an accurate and fully completed application is key to facilitating your credentialing review process smoothly. Remember, attaching additional sheets for extended information is acceptable where space provided is insufficient.

More About Minnesota Uniform Credentialing Application

  1. What is the Minnesota Uniform Credentialing Application?

    The Minnesota Uniform Credentialing Application is a standardized form used for the credentialing process of physicians, dentists, and allied health professionals in Minnesota. It is designed to streamline the reappointment process by providing a uniform method for applicants to submit their personal data, educational background, practice information, and other relevant details.

  2. Who needs to complete the Minnesota Uniform Credentialing Application?

    This application must be completed by physicians, dentists, and allied health professionals seeking reappointment in the state of Minnesota. Allied Health Professionals required to complete this form include those who work under a sponsoring or collaborative physician, such as Physician Assistants (PA-C) or Advanced Practice Registered Nurses (APRN).

  3. What information is required in the application?

    Applicants must provide comprehensive details including personal data, credentialing contact information, education/training history, employment/practice history, any gaps in employment, primary and other practice locations, hospital affiliations, and answers to disclosure questions. All forms and instructions must be completed accurately and legibly, and additional sheets may be attached if more space is needed.

  4. How should I fill out the dates in the application?

    Dates throughout the application should be designated by month, day, and year. It's important to follow this format to ensure clarity and consistency in the application process.

  5. Is it necessary to sign and date the application?

    Yes, it is crucial to sign and date the Attestation Signature and Date statement as well as the Authorization and Release. These signatures must be clearly legible to validate the application.

  6. Can I use abbreviations in the application?

    Applicants are advised not to use abbreviations when completing the application. This guideline ensures that all information is clear and easily understood by those reviewing the application.

  7. What if I need more space than is provided in the application?

    If more space is required than what is available on the application form, additional sheets may be attached. Make sure to reference the question being answered on these sheets to maintain organization and clarity in your application.

  8. What happens if there are gaps in my employment/practice history?

    Applicants must explain any gaps or interruptions of greater than three (3) months in the practice of medicine or professional practice since their last reappointment. Attach additional sheets if needed to provide a full explanation for any such gaps.

  9. In what format should the information be provided?

    All information on the Minnesota Uniform Credentialing Application must be printed in black ink or electronically generated. This requirement ensures that the application is readable and maintains a professional appearance.

Common mistakes

  1. Not providing complete contact information where required is a common mistake. The application asks for thorough details for various sections, including education/training, past employment, hospital affiliations, and references. Ensuring every requested detail, such as street address, phone, fax, and e-mail addresses, is vital for a complete credentialing process. Missing or incomplete information can lead to delays or the inability to verify the applicant's credentials.

  2. Another mistake involves not designating dates clearly with month, day, and year. This application specifically instructs applicants to use this format for all dates to maintain consistency and clarity. Failure to do so can cause confusion and potentially affect the timeline of credentialing, as the reviewed periods may not be accurately understood.

  3. Applicants often overlook the necessity to answer all of the Disclosure Questions and provide explanations for affirmative answers. These questions are critical for assessing any potential risks or concerns associated with the applicant's past professional conduct. Not addressing these questions fully and transparently can impact the review process and outcome.

  4. Last, not signing and dating the Attestation and the Authorization and Release forms is a crucial oversight. All signatures and dates must be clearly legible to verify the applicant’s acknowledgment and consent for the credentialing process. Unsigned or illegible documents cannot be processed, which can halt or void the application.

Documents used along the form

When healthcare professionals in Minnesota fill out the Minnesota Uniform Credentialing Application form, it is often done alongside several other important forms and documents. These documents serve various purposes, from verifying credentials to providing a comprehensive view of the applicant's professional background. Understanding each of these documents can help in creating a well-rounded and accurately represented application package.

  • Curriculum Vitae (CV): A detailed document that outlines the applicant's education, work experience, publications, and other professional activities. It gives a chronological overview of the professional life.
  • Proof of Professional Liability Insurance: This document verifies that the applicant has current malpractice insurance, which is crucial for credentialing in most healthcare settings.
  • State Medical License: A copy of the applicant’s current state license to practice medicine is required to ensure the applicant is legally permitted to practice in the state.
  • Board Certification Document: For specialists, documentation verifying board certification in their specialty area demonstrates that they meet the educational and training standards in their field.
  • Drug Enforcement Administration (DEA) Certificate: This certificate is necessary for practitioners who prescribe medications, affirming their registration with the DEA.
  • Continuing Medical Education (CME) Certificates: These documents show the completion of required continuing education credits, ensuring the practitioner stays updated with the latest in medical care.
  • Reference Letters: Letters from colleagues or supervisors can provide insight into the applicant's clinical skills, ethics, and professional conduct.

Together with the Minnesota Uniform Credentialing Application, these documents create a full picture of the applicant’s qualifications, skills, and standings in the medical community. Ensuring each document is current and accurately represents the applicant’s credentials is pivotal in the credentialing process, ultimately facilitating a smooth pathway towards their professional endeavors in the state’s healthcare system.

Similar forms

  • The Professional License Application shares similarities with the Minnesota Uniform Credentialing Application as both require detailed personal information, professional qualifications, and licensure details. They are pivotal for verifying the credentials of professionals, ensuring they meet the necessary qualifications to practice within their respective fields.

  • The Medical Staff Privileges Application closely resembles the Minnesota Uniform Credentialing Application in its purpose to gather comprehensive professional history, education, and affiliations. Key to granting practitioners access to work within hospitals or medical facilities, these applications assess their capability and compatibility with the institution's standards.

  • Professional Liability Insurance Application is akin to the Minnesota Uniform Credentialing Application as both necessitate thorough disclosure of the applicant’s professional history, including any past claims or licensure issues, to evaluate risk and eligibility for coverage or credentialing. This ensures that professionals are responsibly and adequately insured.

  • The Employment Application for Health Professionals parallels the Minnesota Uniform Credentialing Application in collecting detailed personal and professional data to evaluate the suitability of a candidate for a position. Both scrutinize the individual's background, experience, and qualifications to ensure they align with job requirements.

  • Lastly, the Continuing Medical Education (CME) Certification Application shares aspects with the Minnesota Uniform Credentialing Application by necessitating information on recent educational endeavors and qualifications. Both forms play a crucial role in maintaining up-to-date professional standards and ensuring continuous improvement in practice.

Dos and Don'ts

When completing the Minnesota Uniform Credentialing Application form, it's crucial to pay attention to detail and adhere to the instructions provided to ensure accurate and complete submissions. Below are lists of do's and don'ts to guide applicants through this process efficiently.

Do:
  • Fill out the application completely: Ensure that no section is left blank unless it's clearly not applicable to you. If you need more space, attach additional sheets and reference the question you're answering.
  • Use black ink or electronic generation for clarity: This ensures that the information is legible and able to be scanned or photocopied without issues.
  • Provide detailed contact information: Include full street addresses, phone, fax, and email addresses wherever required, including for education/training, past employment, hospital affiliations, and references.
  • Specify dates accurately: Use month, day, and year formats to designate time frames, which helps in verifying your timeline correctly.
  • Answer all questions truthfully: This includes responding to the Disclosure Questions thoroughly and providing explanations for affirmative answers.
  • Sign and date the application where necessary: The Attestation Signature and Date statement and the Authorization and Release sections must be signed and dated to validate the application.
  • Review the application before submitting: Verify that all information is correct and complete to the best of your knowledge.
  • Include any necessary supporting documents: Attach any required additional sheets or documents that support your application or provide further clarification.
  • Check for legibility: Whether completing the form by hand or electronically, ensure all entries are clear and easily readable.
  • Adhere to deadlines: Submit the completed application within any given time frames to avoid delays in processing.
Don't:
  • Use abbreviations: Avoid using acronyms or abbreviations unless explicitly allowed, as they can cause confusion.
  • Leave gaps in your employment or practice history: Account for all time periods since your last credentialing or reappointment. Explain any gaps longer than three months to avoid questions about your professional timeline.
  • Forget to attach additional pages if needed: If you require more space for any question, remember to attach extra pages. Ensure these are clearly referenced back to the original question.
  • Submit without signatures: Failing to sign and date the necessary sections can invalidate your application.
  • Omit explanations for affirmative disclosure responses: If you answer affirmatively to any disclosure question, provide a full explanation as requested.
  • Provide incomplete contact information: Every section asking for contact details should be filled out fully to enable easy communication.
  • Ignore instructions for allied health professionals: If applicable, ensure that the specific box for Allied Health Professionals is completed as per the instructions.
  • Rush through filling out the form: Taking the time to fill out the application carefully can prevent errors and omissions.
  • Use non-black ink if filling out by hand: Other colors may not photocopy or scan well, potentially making your application difficult to process.
  • Assume information is not important: If a section is included in the application, it needs to be filled out unless clearly stated otherwise.

Misconceptions

When it comes to the Minnesota Uniform Credentialing Application form, there are several misconceptions that healthcare professionals may have. Understanding these can help in completing the application more efficiently and accurately.

  • Misconception 1: Only Physicians Need to Complete It - Contrary to this belief, not only physicians but also dentists and allied health professionals are required to complete the application. This is a pivotal aspect for ensuring all relevant medical practitioners are credentialed appropriately.

  • Misconception 2: Personal Information Isn’t Checked Thoroughly - While it might seem like mere formality, every piece of personal information provided in the application is verified. This includes checking past aliases and ensuring the listed home address is current. Such diligence is crucial for maintaining the integrity of the medical profession.

  • Misconception 3: Employment Gaps Are Overlooked - Every gap in employment or practice must be explained, regardless of the reason. Unexplained gaps can raise concerns about the applicant's professional journey. It’s important to remember that transparency in the application process is valued and necessary for a successful credentialing outcome.

  • Misconception 4: The Application Process Is Just a Formality - This process is a rigorous review of an applicant's qualifications, past employment, training, and any disciplinary actions. It's designed to ensure that health professionals meet the high standards required to practice. Taking it lightly or assuming it’s merely procedural can lead to delays or rejection of the application.

Understanding the purpose and requirements of the Minnesota Uniform Credentialing Application can significantly impact the credentialing process. It's about more than filling out forms; it's a comprehensive review that serves to uphold the quality and trust in healthcare services.

Key takeaways

The Minnesota Uniform Credentialing Application plays a crucial role in the process of reappointment for physicians, dentists, and allied health professionals within the state. Understanding how to complete this form accurately is essential for maintaining credentials and ensuring compliance with state regulatory standards. Below are key takeaways to aid applicants in navigating this form.

  • Complete accuracy and legibility are mandatory for all sections of the application, including attachments. This ensures that processing is not delayed due to errors or illegible information.
  • Abbreviations should be avoided to prevent confusion or misinterpretation of the information provided. Clarity in communication is key to the credentialing process.
  • All required signatures and dates must be clearly legible to validate the application. This includes the Attestation Signature (Page 12), Authorization, and Release (Page 13).
  • Applicants must provide a full street address, along with phone, fax, and email details wherever requested. This includes sections detailing education, training, past employment, hospital affiliations, and references.
  • For those sections requiring dates (e.g., employment history, education, etc.), the month, day, and year format is required to ensure an accurate timeline of an applicant’s professional history.
  • If additional space is needed beyond what is provided in the form, applicants are encouraged to attach extra sheets referencing the question being answered. This ensures a comprehensive and orderly presentation of information.
  • The application stipulates the use of black ink or electronic generation for all printed information, reinforcing the need for clear and professional documentation.

It's evident that the Minnesota Uniform Credentialing Application demands meticulous attention to detail and accuracy from applicants. By adhering to the outlined requirements and ensuring complete and legible submissions, healthcare professionals can navigate the reappointment process more smoothly, ultimately supporting their commitment to providing quality care within Minnesota.

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