Credentialing Questionnaire Template

Credentialing Questionnaire
Name
First NameLast Name
Date of birth
MonthDayYear
Date
Gender
Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
If yes, specify the board and date of certification
State Medical License(s)
Rows State License Number Expiration Date
1
2
Medical School
Rows Name of Institution Degree Obtained Graduation Date
Friendliness
Residency Training
Rows Institution Name Specialty Start Date End Date
1
Fellowship Training (if applicable)
Rows Institution Name Subspecialty Start Date End Date
1
Current Practice Location
Rows Facility Name Address Phone Number
1
Current Insurance Provider
Rows Provider Name Policy Number Coverage Limits Expiration Date
1
Previous Insurance Providers (last 5 years)
Rows Provider Name Policy Number Coverage Dates Reason for Leaving
1
Professional References
Rows Name Relationship Contact Information
1
2
3
Have you ever had any disciplinary actions taken against you by any licensing board or professional organization?
If yes, please provide details
Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?
If yes, please provide details
Have you ever been involved in any malpractice claims or suits?
If yes, please provide details
Do you have any physical or mental health conditions that could impair your ability to practice?
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:

Rows	State	License Number	Expiration Date
1
2

Rows	Name of Institution	Degree Obtained	Graduation Date
Friendliness

Rows	Institution Name	Specialty	Start Date	End Date
1

Rows	Institution Name	Subspecialty	Start Date	End Date
1

Rows	Facility Name	Address	Phone Number
1

Rows	Provider Name	Policy Number	Coverage Limits	Expiration Date
1

Rows	Provider Name	Policy Number	Coverage Dates	Reason for Leaving
1

Select theme:

Rows	Name	Relationship	Contact Information
1
2
3