PROMOTUS PRACTITIONER CREDENTIALING                    APPLICATION FROM                                                                                  
This secure form is used to gather information about you so that PROMOTUS can provide credentialing services to your facility. This form requires personal information, education and training information, licensure and other professional information in detail. Once submitted, you'll receive a confirmation email of completion. It is important that you either e-mail, fax, or upload all the required supporting documents to complete your application with PROMOTUS. When your profile is complete and you have submitted all supporting documents, you will receive notification of profile completion by your credentialing specialist at PROMOTUS.
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Practice Name *
Person Completing Form *
Phone Contact *
Contact Email *
Practitioner's Name *
Practitioner's Email *
NPI (Individual) *
NPI (Group/Practice) *
Date of Birth *
MM
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DD
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YYYY
Gender *
Social Security No. *
Do you have a CAQH Account? *
If you do have a CAQH Account Please Answer Provide the Following: CAQH ID, CAQH Username, CAQH Password *
Primary Office Location: Street, City, State *
Phone *
Personal Information: Address - Street, City, State *
Marital Status *
Other Names Used
City of Birth *
State of Birth *
Country of Birth *
Active Discharge *
Service Date From
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Service Date To
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Rank
Branch
Education and Training: Please indicate that all information provided on CV is reflective of your education and training to date. If all entries are current and accurate please send in a separate attachment to Yanique@thenewhopemhcs.com *
Languages: List any Foreign Languages Spoken by you.
Board/Specialty
Clear selection
Primary Specialty
Board Certified
Clear selection
Board
Initial Certification Date
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DD
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YYYY
Last Certification Date
MM
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DD
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YYYY
Expiration Date
Certification Number
Second Specialty
Clear selection
Secondary Specialty
Board Certified (Secondary Specialty)
Clear selection
Board (Secondary Specialty)
Initial Certification Date (Secondary Specialty)
MM
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DD
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YYYY
Last Certification Date (Secondary Specialty)
MM
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DD
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YYYY
Expiration Date (Secondary Specialty)
MM
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DD
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YYYY
Certification Number (Secondary Specialty)
Notes about Board/Specialty section, i.e., additional specialty, information about expiration, etc.
Hospital Affiliation: Provide detailed items that are not contained on your CV. Complete dates and addresses are required, so if the information is not on CV, then complete the details for each item below. PROMOTUS must have this information to begin your credentialing process. *
Are complete affiliation details included start/end date on CV? *
If no, then please complete the information for each present and past hospital affiliation starting with the name of your primary hospital.
Staff Privileges for Primary Hospital *
Admitting Privileges for Primary Hospital *
Primary Hospital Start Date
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DD
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YYYY
Primary Hospital End Date
MM
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DD
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YYYY
Name of Hospital ( Other hospital affiliation)
Staff Privileges (Other hospital affiliation) *
Admitting Privileges (Other hospital affiliation) *
Name of Professional Association
Enrollment Date
MM
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DD
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YYYY
Name of Professional Association
Enrollment Date
MM
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DD
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YYYY
Professional License Type *
License Number *
Issue State *
Issue Date *
MM
/
DD
/
YYYY
Expiration Date *
Restrictions (If yes please explain in section marked other) *
License Type (Use this section if you have multiple licenses)
License Number
Issuing Board
Issue State
Issue Date
MM
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DD
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YYYY
Expiration Date
Restrictions (If yes please explain in section marked other).
Clear selection
Education Commission for Foreign Medical Graduate (ECFMG) No.
Date Issued
MM
/
DD
/
YYYY
DEA Number
Expiration Date
Status
Clear selection
CDS No. (State controlled dangerous substance certificate. Write NONE if applicable)
State
Expiration Date
Status
Clear selection
Special Certification (CPR, BLS, ACLS, etc.)
Clear selection
If yes please state certifications
Certification No.
Start Date
MM
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DD
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YYYY
End Date
MM
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DD
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YYYY
Certification Authority
Additional Certification (Please state any additional certification that you have).
Certification No. (Additional certification).
Start Date (Additional certification)
MM
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DD
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YYYY
End Date (Additional Certification)
MM
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DD
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YYYY
Certification Authority
Medicare ID
Medicaid ID
Professional Liability Insurance Information *
Current Policy No. *
Name of Carrier *
Coverage From
MM
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DD
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YYYY
Coverage From *
MM
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DD
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YYYY
Coverage To *
MM
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DD
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YYYY
Number of Claims Filed (write zero in none) *
Tail Coverage *
Single Limits Amount *
Aggregate Limits Amount (Recommend minimum amount of 3 million) *
Exclusions *
Status *
Do you have other coverage to report? *
Reference Full Name ( You must provide 3 references with application starting with first name followed by surname)
Address: Street, City, State
Phone Contact
Fax
Email
Dates of Association: From
MM
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DD
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YYYY
Dates of Association: To
MM
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DD
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YYYY
Reference # 2 (First name followed by surname)
Address: City, Street, State, Zip
Phone Contact
Fax
Email
Dates of Association: From
MM
/
DD
/
YYYY
Dates of Association: To
MM
/
DD
/
YYYY
Reference # 3 (First name followed by surname)
Address: Street, City, State, Zip
Phone Contact
Fax
Email
Attestation Questions: (Please answer all)                                                                                                                                        Has your license to practice in your profession ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have your ever been subject to a consent order, probation or any conditions or limitations by any state licensing board? *
If yes, please provide details
Hospital Privileges and Other Affiliations                                                                                                                                                         Have your clinical privileges or medical staff membership at any hospital or healthcare institution been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings towards any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?                                                                                                     *
If yes, please provide details
Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigations? *
If yes, please provide details
Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, or PHOs? *
If yes, please provide details
Education, Training and Board Certification                                                                                                         Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? *
If yes, please provide details
Have you ever, while under investigation or to avoid an investigation , voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical program? *
If yes, please provide details
Have any of your board certification or eligibility ever been revoked? *
If yes, please provide details
Have you ever chosen not to re-certify or voluntarily surrendered your board certification (s) while under investigation? *
If yes, please provide details
DEA or CDS                                                                                                                                                                       Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied, renewal, or voluntarily or involuntarily relinquished?     *
If yes, please provide details
Medicare, Medicaid or other Governmental Program Participation                                                                                                Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid Program, or in regard to other federal or state governmental healthcare plans or programs? *
If yes, please provide details
Other Sanctions or Investigations                                                                                                                             Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authority entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?         *
If yes, please provide details
To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? *
If yes, please provide details
Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g. CLIA, OSHA etc.) *
If yes, please provide details
Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency? *
If yes, please provide details
Malpractice Claims History                                                                                                                                      Have you had any malpractice actions within the past 10 years (pending, settled, arbitrated, mediated, or litigated)? *
Please provide details in each case
Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier base on your individual liability history? *
If yes, please provide details
Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history? *
Criminal History                                                                                                                                                                Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions or duties as a medical professional? *
Have you ever been convicted of, pled guilty to or pled nolo contendere to any felony including an act of violence, child abuse or sexual offence? *
If yes, please provide details
Have you ever been court-martialed for actions related to your duties as a medical professional? *
If yes, please provide details
Ability to Perform Job                                                                                                                                                                                    Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify  a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal us of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It does not  include the use of a drug taken under the supervision by a licensed healthcare professional, or other uses authorized by the Controlled Substances Act or other provision of Federal Law. The term does include, however, the unlawful use of prescription controlled substances. *
If yes, please provide details
Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? *
If yes, please provide details
Do you have any reason to believe that you would pose a risk to the safety or well being of your clients. *
If yes, please provide details
Are you unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation? *
If yes, please provide details
Please indicate that you have emailed the following document *
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