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For Credentialing Staff Use OnlySpecialtyDate Application ReceivedAttach a recent 2” x 2”passport size photograph forthe master file and eachfacility marked on thisapplicationDate Application SignaturePERSONAL DATANOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS1. Name2. Other Name(s) Previously Used Effective3. Social Security Number 4. UPIN# 5. Medicaid6. Medicare# 7.NPI (National Provider Identifier)8. Tax ID# Name Affiliated with Tax ID#8A. Other Tax ID’s (Attach separate sheet if applicable)9. Place of Birth Date of Birth10. Gender 1 . Citizenship1 . If Not US Citizen: Visa # Status Expiration Date13. 6WDWH DQG IHGHUDO UHJXODWRUV DQG DFFUHGLWDWLRQ RUJDQL]DWLRQV DUH UHTXHVWLQJ WKDW KHDOWK SODQV FROOHFW DGGLWLRQDO GHPRJUDSKLF LQIRUPDWLRQ DERXW WKHLU SURYLGHUV Race (ex:Caucasian, African-American, etc.) Ethnicity (ex:Spanish, Russian,etc.)14. Name of Spouse/Significant Other15. Local ResidenceComplete AddressTelephone NumberE-Mail Address16. Date of Relocation to NV (If Applicable) Date Expected to Begin PracticeSpecialty Staff Status RequestedCurrent Address (if different from above)NDOI-901 Rev. 12/161
NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS17. Alternate Care of Hospitalized Patients: If you do not apply for admitting privileges, list thename/names of physicians or groups with whom you have established a current hospital admission coverageagreement:OFFICE INFORMATION18. Local Primary Practice/Group NameComplete Office AddressOffice PhoneFAX NumberE-MailWebsite URLPreferred Method of Contact Phone FAX E-Mail18A. Other Practice Locations (Please attach a separate sheet)19. Office/Credentialing Contact Name & AddressTitlePhone NumberFAX NumberE-Mail Address20. Secondary/Billing Office AddressOffice PhoneFAX NumberE-Mail21. Practitioner’s Beeper/Cell Number Answering Service Number22. Practitioner Call Coverage23. Are you currently accepting new patients into your practice? YES NO(If NO, your name may not appear in the Managed Care directory)24. Office Hours MondayTuesdayWednesdayThursday Friday SaturdaySunday25. Describe after-hours patient care operation.26. Any practice restrictions? (Specify)27. Office accessible to disabled pursuant to ADA guidelines? YES NO28. Languages (other than English) Spoken in Your OfficeA. By ProviderB. By Staff29. Do you wish to have these languages listed in a Provider Directory? YES NONDOI-901 Rev. 12/162
NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS30. Do you accept Medicare assignment? YES NO31. Is your office within twenty (20) minutes of the facilities at which you have privileges? YES NO32. Office Laboratory services provided?33. Office Radiology services provided?34. Additional office testing available?35. Surgical facilities/services provided at the office?36. Do you wish to be listed (for Managed Care) as PCP Specialist BothPROFESSIONAL LICENSESAttach copies of license(s)37. Nevada Medical/Dental/AHP license # Date Issued Date ExpiresOther State Licenses:StateNumberIssue DateExpiration DateDEA AND NEVADA STATE PHARMACY REGISTRATIONAttach copies of certificates38. Federal DEA Registration # Date ExpiresNevada State Pharmacy # Date ExpiresOther State Pharmacy Licenses:StateNumberIssue DateExpiration DateNDOI-901 Rev. 12/163
39. Examinations Taken – Attach CopiesECFMG NoDate of CertificationFLEX ExamDate TakenUSMLE No.Date TakenNational Board of Medical Examiners Date Taken40. Other Training or Certification (Check and complete all that apply, attach copies for hospitals only)TYPEDate of CertificationExpiration DateCPRACLSATLSBLSNALSPALSOTHERNDOI-901 Rev. 12/164
EDUCATION/TRAINING41. Pre-Medical/Dental/AHP EducationFacility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrDegree Earned42. Medical/Dental/AHP EducationFacility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrDegree Earned43. Internship (if applicable)Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram DirectorNDOI-901 Rev. 12/165
44. Internship (if applicable)Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram Director45. Residency (if applicable)Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram Director46. Other Residency (if applicable) Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram DirectorPhoneFAXNDOI-901 Rev. 12/166
NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS47. Fellowship (if applicable)Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram Director48. Fellowship (if applicable)Type (Specialty)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram Director49. Fifth Pathway (Required to be completed by Non-USA Grads in lieu of ECFMG Certification)(if applicable)Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram DirectorNDOI-901 Rev. 12/167
OTHER POST GRADUATE EDUCATIONList in chronological order and include copies of certificates50.Facility NameSpecialty & Degree AwardedMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram Director51.Facility NameMailing AddressPhoneFAXFROM: Mo/YrTO: Mo/YrProgram DirectorNDOI-901 Rev. 12/168
BOARD CERTIFICATIONSAttach copy of certificate(s)This section pertains to specialty boards that are organized and recognized by the American Board of MedicalSpecialties or American Osteopathic Association. (AHPs List Board certification as applicable)52.Name of Specialty BoardMailing AddressDate of Certification Expiration DateIf not certified, indicate current statusIf not certified, are you scheduled to take the exam? If so, when?53.Name of Specialty BoardMailing AddressDate of Certification Expiration DateIf you have ever failed a board examination, please indicate Board and date54.Name of Specialty BoardMailing AddressDate of Certification Expiration DateIf you have ever failed a board examination, please indicate Board and date55. Other Board CertificationMILITARY SERVICEAttach copy of discharge papers.56. Have you ever served or are you currently serving in the United States Military? YES NOIf YES, Branch of ServiceFROM / TO / Type of DischargeDD214 (provide copy with application)NDOI-901 Rev. 12/169
NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALSEMPLOYED FACULTY POSITIONS AND ACADEMIC AFFILIATIONSList in chronological order. Do not include hospital staff memberships or surgical center affiliations.57.Facility NameFROM: Mo/YrTO: Mo/YrMailing AddressPhone NumberFAX NumberPositionDepartmentReason for Leaving58.Facility NameFROM: Mo/YrTO: Mo/YrMailing AddressPhone NumberFAX NumberPositionDepartmentReason for Leaving59.Facility NameFROM: Mo/YrTO: Mo/YrMailing AddressPhone NumberFAX NumberPositionDepartmentReason for LeavingNDOI-901 Rev. 12/1610
PRIVATE PRACTICE AND OTHERList any private practice affiliations or other employment since completion of medical/dental/AHP school. Forany time period not covered by an affiliation or training, please provide a written explanation.60.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number61.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number62.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number63.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberNDOI-901 Rev. 12/16FAX Number11
64.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number65.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number66.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX Number67.Affiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberNDOI-901 Rev. 12/16FAX Number12
HOSPITAL AND OTHER HEALTH CARE ENTITY MEMBERSHIPSList ALL hospitals and surgical centers where you currently have or have had affiliation, membership and/or have beengranted privileges. If you have withdrawn an application or you are no longer affiliated with a hospital or surgical center,provide an explanation on a separate page. If an explanation is attached, make sure the original entry is denoted. For anytime period not covered by an affiliation or training, please provide a written explanation.68. Hospital/SurgicalCenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attached69. Hospital/Surgical CenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attached70. Hospital/Surgical CenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attachedNDOI-901 Rev. 12/1613
71. Hospital/Surgical CenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attached72. Hospital/Surgical CenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attached73. Hospital/Surgical CenterAffiliated WithFROM: Mo/YrTO: Mo/YrPerson to Contact for VerificationMailing AddressPhone NumberFAX NumberStaff Category ( ) Check here if explanation is attachedNDOI-901 Rev. 12/1614
PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCEAttach copy of present policy face sheet and list ALL insurance carriers for the past 10 years. Attach additional sheets ifnecessary.74. Present Carrier for Nevada PracticeMailing AddressPhone NumberFAX NumberPolicy #Effective DateExpiration DateAmounts of Coverage: Occurrence/Claim Aggregate 75. Previous CarrierMailing AddressPhone NumberFAX NumberPolicy #Effective DateExpiration DateAmounts of Coverage: Occurrence/Claim Aggregate 76. Previous CarrierMailing AddressPhone NumberFAX NumberPolicy #Effective DateExpiration DateAmounts of Coverage: Occurrence/Claim Aggregate 77. Previous CarrierMailing AddressPhone NumberFAX NumberPolicy #Effective DateExpiration DateAmounts of Coverage: Occurrence/Claim Aggregate NDOI-901 Rev. 12/1615
CONTINUING MEDICAL EDUCATION/CEU78. Attach documentation of continuing medical education/CEU courses attended during the previous two (2)years, if applicable. Indicate which is specialty specific. Approved documentation includes a copy ofCME/CEU Certificates or a list from a recognized professional organization such as AOA, AAFP, AMA,AAOS, etc.PEER REFERENCESMD/DO, DDS/DMD, etc.: List the names and complete information of three (3) peer references, other thanassociates, relatives, prospective associates or training directors with equivalent licensure (MD/DO,DDS/DMD, etc.) who have, within the past three (3) years, personal knowledge of your current clinicalabilities, ethical character and ability to work with others. At least two of the references should be of your samespecialty.AHPs: List three physicians who are familiar with your clinical abilities and recent practice. Note: referenceswill be evaluated primarily by the extent of direct clinical observation and other work with the applicant. If youare applying for CRNFA privileges, some Entities require each physician to complete a Statement of PhysicianSponsorship form (contact Entity for form).79.Peer ReferenceSpecialtyComplete Mailing AddressPhone NumberFAX Number80.Peer ReferenceSpecialtyComplete Mailing AddressasfasPhone NumberFAX Number81.Peer ReferenceSpecialtyComplete Mailing AddressPhone NumberFAX NumberNDOI-901 Rev. 12/1616
PRACTITIONER QUESTIONNAIRE82. If answers to any of the following questions is YES, please provide full details on a separate sheet, toinclude date of occurrence, description of events and current status.A.Has your license to practice medicine in any jurisdiction ever been denied,revoked, voluntarily or involuntarily terminated, relinquished, suspended,otherwise limited or restricted, or been made subject to a program of probation,or have you ever been issued a citation or letter of reprimand by the licensingagency, or have formal or informal proceedings, or investigations, toward anyof those ends ever been commenced? YES NOB.Has your medical staff membership or medical staff status at any hospital orcomparable acute or long term care facility or ambulatory surgery center orcomparable facility, ever been denied, revoked, voluntarily or involuntarilyterminated, relinquished, suspended, or restricted or limited, based on patientcare or professional conduct reasons, or have formal or informal proceedings,or investigations, toward any of those ends ever been commenced? YES NOC.Have your admitting or clinical privilege(s) at any other hospital, or at anycomparable acute or long term care facility, or ambulatory surgery center orcomparable facility, ever been denied, revoked, voluntarily or involuntarilyterminated, relinquished, suspended, or restricted or limited, based on patientcare or professional conduct reasons, or have formal or informal proceedings,or investigations, toward any of those ends ever been commenced? YES NOD.Have you ever voluntarily or involuntarily relinquished medical staffmembership or status, admitting or clinical privileges, withdrawn anapplication for membership or privileges at any hospital or comparable acute orlong term care facility, or ambulatory surgery center or comparable facility,after notification of the actual or imminent commencement of a formal orinformal review, or investigation of your practice, credentials or professionalconduct? YES NOE.Has your membership, participation, privileges, contractual affiliation or otherstatus with any health maintenance organization, medical group, ambulatory oroutpatient care center, clinic, independent practice association, preferredprovider organization, or any other comparable health care entity ever beendenied, revoked, voluntarily or involuntarily terminated, suspended, restrictedor limited based upon patient care or professional conduct grounds, or haveformal or informal proceedings, or investigations toward any of those endsever been commenced? YES NONDOI-901 Rev. 12/1617
F.Have you ever voluntarily or involuntarily relinquished membership,participation, privileges, a contractual affiliation or other comparable statuswith any health maintenance organization, medical group, ambulatory oroutpatient care center, clinic, independent practice association, preferredprovider organization, or any other comparable health care entity afternotification of the actual or imminent commencement of a formal or informalreview or investigation, of your practice or professional conduct? YES NOG.Has your membership or status in any state or local professional society orother comparable medical organization ever been denied, revoked, voluntarilyor involuntarily terminated, suspended or restricted based upon patient care orprofessional conduct concerns, or have formal or informal proceedings, orinvestigations toward any of those ends ever been commenced?Has your status as a participating provider in the Medicare, Medicaid, orTricare (formerly Champus) programs ever been sanctioned, denied,suspended, voluntarily or involuntarily terminated, limited or revoked, or haveformal or informal proceedings, or investigations toward any of those endsever been commenced? YES NOI.Has a letter of concern or reprimand ever been issued to you? YES NOJ.Have you ever been denied professional liability insurance or has yourpolicy ever been canceled? YES NOK.(1) Have you ever been named in a complaint based on allegations ofprofessional negligence or professional misconduct or have you ever receivednotice of an intent to commence litigation of that type? Note: Make copies ofthe attached Malpractice Claim Information Worksheet and complete foreach case. YES NO(2) With regard to any suit, has it resulted in a judgment, a settlement, or otherfinal disposition, or is it still pending? Note: Make copies of the attachedMalpractice Claim Information Worksheet and complete for each case. YES NOL.Does your professional liability (malpractice) coverage exclude you fromperforming any specific procedures(s) or practicing portions of your specialtyfor which you are requesting privileges? YES NOM.Has your specialty board certification or eligibility ever been denied, revoked,voluntarily or involuntarily terminated, suspended, or have formal or informalproceedings, or investigations toward any of those ends ever beencommenced? YES NON.Has your Drug Enforcement Agency or other controlled substancesauthorization ever been denied, revoked, voluntarily or involuntarilyterminated, suspended, or restricted or have formal or informal proceedings, orinvestigations toward any of those ends ever been commenced?H.NDOI-901 Rev. 12/1618 YES NO YES NO
O.Have you ever been convicted of a criminal offense other than a minor trafficviolation? YES NOP.Are you now or have you ever been addicted to a controlled substance oralcohol? If the answer to this question is yes, please provide the name,address and a full description of any rehabilitation program in which youare now participating or in which you have participated as well as thename and title of the individual who can describe your care andparticipation in that program. An organization may require that youcomplete a Health Status Form which provides the name and title of theindividual/organization (counselor/diversion program/treating provider)who can advocate on behalf of your sobriety status. YES NOQ.Do you currently use illegal drugs? YES NOR.Do you have any mental or physical condition that may significantly affectyour ability to practice medicine or to exercise the particular privileges thatyou have requested?If so, do you believe that, with reasonableaccommodation, you will be able to provide care meeting the standardscontrolling the award of privileges and status that you seek? YES NOS.Would you require an accommodation in order for you to exercise medicalstaff duties or the privileges requested safely and completely? YES NONDOI-901 Rev. 12/1619
Standard Authorization, Attestation and Release for Health Plans, Health Insurers andHealth Care Organizations(Not for Use for Employment Purposes)Purpose of FormThis form has been developed for use by Nevada health plans and health insurers, and may beused by hospitals and other healthcare organizations. Its purpose is to provide a singleconsolidated form for use by applicants for participation as a provider (hereinafter,“Participation”) with health plans or health in
For Credentialing Staff Use Only Date Application Signature_ PERSONAL DATA NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS . Do you wish to have these languages listed in a Provider Directory? _YES _NO 17. _ NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS A
