Credentialing Questionnaire Template

Credentialing Questionnaire
Name
First NameLast Name
Date of birth
MonthDayYear
Date
Gender
MaleFemaleOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
National Provider Identifier (NPI) Number
Current Position/Title
Primary Specialty
Subspecialty (if applicable)
Board Certification
YesNo
If yes, specify the board and date of certification
State Medical License(s)
State License Number Expiration Date
1
2
Medical School
Name of Institution Degree Obtained Graduation Date
Friendliness
Residency Training
Institution Name Specialty Start Date End Date
1
Fellowship Training (if applicable)
Institution Name Subspecialty Start Date End Date
1
Current Practice Location
Facility Name Address Phone Number
1
Current Insurance Provider
Provider Name Policy Number Coverage Limits Expiration Date
1
Previous Insurance Providers (last 5 years)
Provider Name Policy Number Coverage Dates Reason for Leaving
1
Professional References
Name Relationship Contact Information
1
2
3
Have you ever had any disciplinary actions taken against you by any licensing board or professional organization?
YesNo
If yes, please provide details
Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?
YesNo
If yes, please provide details
Have you ever been involved in any malpractice claims or suits?
YesNo
If yes, please provide details
Do you have any physical or mental health conditions that could impair your ability to practice?
YesNo
If yes, please provide details
Attestation and Signature

I hereby attest that the information provided in this questionnaire is true and complete to the best of my knowledge. I understand that providing false information may result in the denial or revocation of my credentialing application.
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

	State	License Number	Expiration Date
1
2

	Name	Relationship	Contact Information
1
2
3