California Participating Practitioner Application (CPPA) Instructions

Check this box if you or your office has received accreditation from the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).

Check this box if you or your office has received accreditation from the Institute for Medical Quality / Accreditation Association for Ambulatory Health Care (IMQ‑AAAHC).

Check this box if you or your office holds Medicare certification.

Check this box if you or your office participates in or is certified by the Child Health and Disability Prevention Program (CHDP).

Check this box if you or your office is enrolled in or certified by California Children Services (CCS).

Check this box if you or your office has accreditation or licensure from The Medical Quality Commission (TMQC).

Check this box if you or your office participates in or is certified by the Comprehensive Perinatal Services Program (CPSP).

Check this box if you or your office provides family planning services or holds a family planning certification/accreditation.

Check this box if you or your office has any other accreditation, certificate, or licensure not listed above and provide the details in the adjacent field.

Enter the name of any other accreditation, certificate, or licensure not listed above (for example program or agency name). Fill only if 'Other' is 'Yes'.

Check this box if you have applied for board certification other than those listed on the prior page.

Check this box if you have not applied for any board certification other than those listed on the prior page.

Enter the name(s) of the board(s) you have applied to for certification and the corresponding date(s) of application or examination; list multiple entries separated by commas or line breaks. Fill only if 'Have you applied for board certification? — Yes' is 'Yes'.

Check this box if the age limitation applies to the Primary office.

Check this box if the age limitation applies to the Secondary office.

Check this box if the age limitation applies to the Tertiary office.

Enter the full name of the allied health professional (e.g., Jane Doe) being listed in the first row. Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional role or specialty of the person listed in the first row (e.g., nurse practitioner, physician assistant, psychologist). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional license or registration number for the allied health professional listed in the first row as issued by the relevant licensing authority. Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the full name of the allied health professional listed in the second row (e.g., Jane Doe). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional role or provider type for the person in the second row (e.g., nurse practitioner, physician assistant, psychologist). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional license or registration number assigned to the provider listed in the second row by the issuing authority. Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the full name of the allied health professional listed in the third row (e.g., first and last name). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional role or provider type for the person in the third row (e.g., Nurse Practitioner, Physician Assistant, Psychologist). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the professional license number associated with the allied health professional listed in the third row. Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Check this box if your group/office provides local anesthesia.

Check this box if your group/office provides regional anesthesia (for example, nerve blocks or epidurals).

Check this box if your group/office provides conscious (procedural) sedation where the patient remains responsive.

Check this box if your group/office provides general anesthesia.

Check this box if your group/office does not provide any anesthesia services.

Check this box if your group/office provides an anesthesia type not listed and write the specific type in the adjacent space.

Enter the name or description of any anesthesia type not listed (Other) that you provide in your group/office. Fill only if 'Other (please specify)' is 'Yes'.

Enter the full legal name of the answering service company that provides call coverage.

Enter the street mailing address of the answering service, including suite or PO Box if applicable.

Enter the city where the answering service is located.

Enter the state, province, or region where the answering service is located.

Enter the postal ZIP or ZIP+4 code for the answering service's address.

Provide a contact email address for the answering service.

Enter your primary telephone number (include area code and country code if applicable), using digits and any needed separators such as spaces, dashes, or parentheses.

Enter your fax number including area code and country code if applicable, or leave blank if you do not have a fax number.

Enter your mobile/cell phone number (include area code and country code if applicable), using digits and optional separators as needed.

Enter your pager number if you have one (include area code and country code if applicable), or leave blank if not applicable.

Enter the applicant's primary email address for professional/contact purposes (e.g., [email protected]).

Enter the applicant's country of citizenship or immigration status; if not a U.S. citizen, include Alien Registration (A-) number or note and be prepared to provide a copy of the Alien Registration Card.

Enter your current legal family/surname exactly as it appears on official documents.

Enter your legal given/first name as it appears on official documents.

Enter your middle name or middle initial (leave blank if none).

List any other names under which you have been known (for example, maiden, former, or professional names), separated by commas.

Enter the applicant's full printed name (legal name) as it should appear on the form. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the date on which the applicant signed this document. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the applicant's full printed name exactly as they wish it to appear on the form.

Enter the date when the applicant signed the form.

Enter the applicant's full printed name exactly as they want it to appear on the application.

Enter the date on which the applicant signed or printed their name for the signature section.

Enter the applicant’s full printed name exactly as they want it to appear on the form.

Enter the date when the applicant signed or completed the printed name field.

Check this box if you answer "Yes" to Question 1, meaning your license to practice medicine, DEA registration, or applicable narcotic registration has at any time been denied, limited, restricted, suspended, revoked, not renewed, subject to probationary conditions, voluntarily or involuntarily relinquished, accepted actions or conditions, fined, received a letter of reprimand, or if any such action is pending.

Check this box if you answer "No" to Question 1, meaning you have never had any of the denials, limitations, restrictions, suspensions, revocations, non‑renewals, probationary conditions, voluntary or involuntary relinquishments, accepted actions or conditions, fines, reprimands, or pending actions described in the question.

Check this box if you have any professional liability lawsuits or arbitrations against you that have been dismissed or are currently pending.

Check this box if you do not have any professional liability lawsuits or arbitrations against you that have been dismissed or are currently pending.

Check this box if your professional liability insurance has ever been terminated, not renewed, restricted, modified (e.g., reduced limits, restricted coverage, surcharged), or if you have ever been denied or given written notice of intent to deny, cancel, not renew, or limit any professional liability insurance or its coverage for any procedures.

Check this box if none of the events in Question 11 have occurred — your professional liability insurance has never been terminated, denied, restricted, modified, or otherwise limited as described.

Check this box if you have any physical or mental condition that would prevent or limit your ability to perform the essential functions of the position/privileges (with or without reasonable accommodations).

Check this box if you do not have any physical or mental condition that would prevent or limit your ability to perform the essential functions of the position/privileges.

Check this box if you have been charged, suspended, fined, disciplined, sanctioned, subjected to probationary conditions, restricted or excluded, voluntarily or involuntarily relinquished eligibility to provide services, or had conditions accepted on your eligibility to provide services (or if any such action is pending).

Check this box if you have never been charged, suspended, fined, disciplined, sanctioned, subjected to probationary conditions, restricted or excluded, voluntarily or involuntarily relinquished eligibility to provide services, had conditions accepted on your eligibility to provide services, and no such action is pending.

Check this box if your clinical privileges, membership, contractual participation, or employment by any medical organization have ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked, not renewed, or are the subject of any pending action for reasons such as possible incompetence, improper professional conduct, or breach of contract.

Check this box if none of the described actions (denial, suspension, restriction, reduction, probationary conditions, revocation, non‑renewal, or any pending action) have ever occurred with respect to your clinical privileges, membership, contractual participation, or employment by any medical organization.

Check this box if you have ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from any medical organization while under investigation (or with an investigation pending) for possible incompetence, improper professional conduct, breach of contract, or related reasons.

Check this box if you have never surrendered, allowed to expire, withdrawn a request for membership or privileges, terminated participation/employment, or resigned from any medical organization while under investigation or with any such action pending for incompetence, improper professional conduct, breach of contract, or related reasons.

Check this box if you have ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program.

Check this box if you have never surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program.

Check this box if you have ever been denied certification or recertification by a specialty board.

Check this box if you have never been denied certification or recertification by a specialty board.

Check this box if you have chosen not to recertify or have voluntarily surrendered your board certification while it was under investigation.

Check this box if you have never chosen not to recertify and have not voluntarily surrendered your board certification while it was under investigation.

Check this box if you have ever been convicted of, pled guilty to, or been placed on deferred adjudication or probation for a criminal offense (other than a misdemeanor traffic offense).

Check this box if you have never been convicted of, pled guilty to, nor been placed on deferred adjudication or probation for any criminal offense (other than a misdemeanor traffic offense).

Check this box if you currently have any criminal actions pending related to the convictions/pleas described in question 8a.

Check this box if you do not currently have any criminal actions pending related to the convictions/pleas described in question 8a.

Check this box if any judgments were entered against you or any settlements were agreed to on your behalf within the last seven (7) years in professional liability cases.

Check this box if no judgments or settlements in professional liability cases have been entered or agreed to on your behalf within the last seven (7) years.

Enter the full name of the attorney(s) you authorize us to contact regarding this matter. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the attorney's primary telephone number, including area code and any extension if applicable. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the attorney's fax number, including area code, for sending documents related to this matter. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the billing company's full mailing street address or P.O. Box for billing correspondence. Fill only if 'None (provide billing info)' is 'Yes'.

Enter the city for the billing company's mailing address. Fill only if 'None (provide billing info)' is 'Yes'.

Enter the state for the billing company's mailing address (use the two-letter abbreviation or full state name). Fill only if 'None (provide billing info)' is 'Yes'.

Enter the postal ZIP or ZIP+4 code for the billing company's mailing address (include the hyphen for ZIP+4 if applicable). Fill only if 'None (provide billing info)' is 'Yes'.

Enter the full legal name of the company that handles billing for this practice (the billing or payor company name). Fill only if 'None (provide billing info)' is 'Yes'.

Enter the full name of the person responsible for billing and billing inquiries for this practice. Fill only if 'None (provide billing info)' is 'Yes'.

Enter the phone number for the billing contact, including area code and extension if applicable. Fill only if 'None (provide billing info)' is 'Yes'.

Enter the practice or billing entity's Federal Tax Identification Number (EIN/TIN) exactly as issued by the IRS. Fill only if 'None (provide billing info)' is 'Yes'.

Enter the legal business or individual name that is registered with the Federal Tax ID provided in the adjacent field. Fill only if 'None (provide billing info)' is 'Yes'.

Check this box if the Primary practice handles your billing.

Check this box if the Secondary practice handles your billing.

Check this box if the Tertiary practice handles your billing.

Check this box if none of the listed practices handles billing and you will provide separate billing company information in the fields below.

Enter the applicant's date of birth.

Enter the applicant's place of birth (for example city, state/province, and/or country).

Enter the applicant's race if they choose to disclose it (e.g., White, Black/African American, Asian, etc.).

Enter the applicant's ethnicity if they choose to disclose it (for example Hispanic/Latino or Not Hispanic/Latino).

List any languages the applicant speaks or uses, optionally indicating proficiency or primary language.

Enter the full name of the board or organization that issued this board certification.

Provide the certificate or license number assigned to this board certification as it appears on the certificate.

Enter the date when this certification was originally awarded or most recently recertified.

If applicable, enter the expiration date of this board certification; leave blank if there is no expiration.

Enter the name of the board or issuing organization for the fourth board certification.

Enter the certificate or license number assigned by the issuing board for the fourth certification.

Enter the date the fourth certification was originally issued or most recently recertified.

Enter the expiration date for the fourth board certification, if any.

Enter the full name of the board or organization that issued this certification.

Enter the certificate or record number assigned by the issuing board for this certification.

Enter the date this certification was originally granted or most recently recertified.

Enter the expiration date of this certification, if applicable; leave blank if there is no expiration.

Enter the full name of the board that issued this certification.

Enter the certificate or license number assigned by the issuing board for this certification.

Enter the date the certification was originally awarded or most recently recertified.

Enter the expiration date of this certification if it has one; leave blank if the certificate does not expire.

Enter the medical specialty or subspecialty for which you intend to seek board certification.

Enter the full name of the board or certifying organization you plan to apply to for certification.

Enter the date of the certification exam you plan to take or have taken.

Provide a brief description of your intent for certification, including eligibility status, planned timeline, and any other relevant details.

Enter the full California medical license number exactly as issued (include any letters or leading zeros).

Enter the date the California medical license was issued.

Enter the expiration date of the California medical license.

Enter the city, county and state where the lawsuit or arbitration was filed. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the official court or docket number for the case, if known. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Provide the date on which the alleged incident occurred that serves as the basis for the lawsuit or arbitration. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the date the lawsuit or arbitration was filed. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the Controlled Dangerous Substances (CDS) certificate or license number issued to you by the regulating authority.

Enter the expiration date of your Controlled Dangerous Substances (CDS) certificate.

List any clinical services, procedures, or treatments that your practice does not perform but that are typically associated with your specialty (separate multiple items with commas or line breaks).

Enter the covering physician's full name, their phone number, and indicate which practice(s) (Primary, Secondary, Tertiary) the coverage applies to.

Enter the covering physician's full name, their phone number, and indicate which practice(s) (Primary, Secondary, Tertiary) the coverage applies to.

Enter the covering physician's full name, their phone number, and indicate which practice(s) (Primary, Secondary, Tertiary) the coverage applies to.

Check this box to indicate you have included the credentialing mailing address for the provider in your submission.

Check this box to indicate you have included a phone number for the credentialing contact.

Check this box to indicate you have included an email address for the credentialing contact.

Check this box to indicate you have provided the name of the credentialing contact person.

Enter the full name of the hospital or institution for your first/current affiliation.

Enter the name of the department, division, or service within the hospital for this affiliation.

Enter the primary street address of the hospital or institution for this affiliation.

Enter the affiliation status that applies (for example: active, provisional, courtesy, temporary).

Enter the city where the hospital or institution is located.

Enter the state or province where the hospital or institution is located.

Enter the ZIP or postal code for the hospital's address.

Enter the primary phone number for medical staff contact at this hospital, including area code and extension if applicable.

Enter the fax number for medical staff contact at this hospital, including area code if applicable.

Enter the month and year when this affiliation began.

Enter the month and year when this affiliation ended, or leave blank if the affiliation is ongoing.

Enter the full name of the hospital or institution for your fourth current affiliation.

Enter the name of the department, division, or service at this hospital associated with your affiliation.

Provide the primary street address of the hospital or institution, including suite or floor if applicable.

Specify your appointment or privilege status at this hospital (for example: active, provisional, courtesy, temporary).

Enter the city where the hospital or institution is located.

Enter the state or province (abbreviation or full name) where the hospital is located.

Enter the postal ZIP or postal code for the hospital's address.

Provide the primary medical staff phone number for this hospital, including area code if applicable.

Provide the medical staff fax number for this hospital, including area code if applicable.

Enter the date when this affiliation or hospital privileges began.

Enter the date when this affiliation or hospital privileges ended, or indicate that it is ongoing.

Enter the full name of the hospital, clinic, or institution for the second/current affiliation.

Enter the department, division, or unit name associated with this affiliation.

Provide the street address for the hospital or institution for this affiliation.

Indicate the appointment status at this institution (for example active, provisional, courtesy, or temporary).

Enter the city where the hospital or institution is located.

Enter the state or province (abbreviation or full name) for the institution's location.

Enter the postal ZIP or postal code for the hospital's address.

Provide the primary phone number for the hospital's medical staff, credentialing office, or main contact.

Provide the fax number for the hospital's medical staff, credentialing office, or main contact.

Enter the start date of this affiliation.

Enter the end date of this affiliation, or leave blank if the affiliation is ongoing.

Enter the full name of the hospital or institution for your third current affiliation.

Enter the department, division, or service name associated with this affiliation.

Enter the hospital's primary street address, including building, suite, or unit information if applicable.

Enter the current status of your privileges at this hospital (for example: active, provisional, courtesy, temporary).

Enter the city where the hospital is located.

Enter the state, province, or region where the hospital is located.

Enter the postal or ZIP code for the hospital's address.

Enter the primary phone number for the hospital's medical staff office, including area code and extension if applicable.

Enter the fax number for the hospital's medical staff office, including area code if applicable.

Enter the start date of this affiliation.

Enter the end date of this affiliation or indicate that it is ongoing.

Enter the applicant's full Drug Enforcement Agency (DEA) registration number exactly as issued (include letters and digits).

Enter the controlled substance schedules the DEA registration authorizes (for example: II, III-V, II-V, etc.).

Provide the expiration date of the DEA registration.

Provide the Federal Tax Identification Number (TIN) associated with the entity that performs or bills for the direct laboratory services.

Enter the billing or legal business name associated with the Federal Tax ID used for the laboratory services.

Specify the type of laboratory service(s) provided (for example: clinical chemistry, microbiology, pathology, phlebotomy, or other).

Enter the Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver number issued to your laboratory or testing site. Fill only if 'PG10 11' is 'Yes'.

Provide the expiration date of the CLIA certificate or waiver for your laboratory. Fill only if 'PG10 11' is 'Yes'.

Check this box when you are submitting the completed, signed, and dated California Participating Practitioner Application (CPPA) — including the attestation questionnaire and Addenda A and B — or when re‑credentialing with any updates.

Check this box when you are including your current CV/resume with work history for the previous five years and written explanations for any gaps of six months or more.

Check this box when you are including a copy of your current, valid, and unrestricted California medical license issued by the appropriate licensing board.

Check this box when you are including a copy of your DEA Controlled Substance Registration Certificate showing a California address, if applicable.

Check this box when you are submitting a current professional liability insurance certificate that shows the policyholder, policy carrier, limits of liability, and the expiration date.

Check this box when you are including a copy of your current board certification, if applicable.

Check this box when you are including a copy of your ECFMG certificate, if applicable.

Check this box when you are a midlevel provider and are submitting a physician supervisory agreement.

Enter your Educational Commission for Foreign Medical Graduates (ECFMG) registration number assigned to foreign medical graduates.

Enter the date the ECFMG number was issued to you.

Check this box if your practice currently participates in electronic data interchange (EDI).

Check this box if your practice does not participate in electronic data interchange (EDI).

Enter the name of the electronic data interchange (EDI) network your practice uses if you indicated participation; leave blank if you do not participate. Fill only if 'Participate in electronic data interchange (EDI) — Yes' is 'Yes'.

Check this box if your practice employs any allied health professionals (e.g., nurse practitioners, physician assistants, psychologists, etc.).

Check this box if your practice does not employ any allied health professionals.

Enter the organization's federal tax identification number (EIN) assigned by the IRS.

Enter the legal name or individual name that is registered with the provided federal tax identification number.

Enter the full name of the fifth international, state, or national medical society or professional organization of which you are a member or applicant.

Check this box if you are an applicant for the organization listed on the fifth organization line in the Organization Name column.

Check this box if you are a current member of the organization listed on the fifth organization line in the Organization Name column.

Enter the full name of the affiliation and its complete mailing address (institution, company, or organization and location).

Enter the specific department, division, or unit within the affiliation where you worked or were associated.

Enter the start date of this affiliation.

Enter the end date of this affiliation.

Provide a brief explanation of why you left this affiliation.

Enter the full name of the international, state, or national medical society or other professional organization for which you are a member or an applicant.

Check this box if, for the first organization listed on this row, you are an applicant seeking membership (not yet a current member).

Check this box if, for the first organization listed on this row, you are currently a member of that organization.

Enter the full name of your first professional reference (for example, Dr. Jane Doe).

Enter the reference's medical specialty or professional title (for example, Cardiology or Attending Physician).

Enter the street address of the reference's primary work location, including suite or floor if applicable.

Enter the city for the reference's work address.

Enter the state or province for the reference's work address (use the usual postal abbreviation if preferred).

Enter the postal ZIP or postal code for the reference's work address.

Enter the reference's primary telephone number, including area code and country code if applicable.

Enter the reference's office fax number, including area code if applicable.

Enter the reference's professional email address for contact.

Enter the full legal name of the current professional liability insurance carrier for this policy.

Enter the policy or certificate number assigned to this insurance by the carrier.

Provide the street address or mailing address for the insurance carrier or its local office.

Enter the city in which the carrier's address is located.

Enter the state or province for the carrier's address.

Enter the postal ZIP or postal code for the carrier's address.

Provide the primary telephone number to contact the insurance carrier or its office.

Provide the fax number for the insurance carrier, if available.

Enter the carrier's website or main URL, if applicable.

Enter the primary email address for contacting the insurance carrier.

Check this box if the first listed professional liability carrier provides tail coverage (yes).

Check this box if the first listed professional liability carrier does not provide tail coverage (no).

Provide the per-claim coverage limit amount for this policy.

Enter the original date when this policy first became effective.

Enter the policy's expiration or end date.

Provide the total aggregate coverage limit for this policy.

Enter the name of the practice, clinic, or employer for this first work history entry.

Enter the full name of the primary contact person at the practice for this entry.

Enter the street address (including suite or building number if applicable) of the practice or employer for this entry.

Enter the city where the practice or employer is located.

Enter the state or province for the practice's address.

Enter the postal ZIP or ZIP+4 code for the practice's address.

Enter the main telephone number for the practice or employer, including area code and extension if applicable.

Enter the fax number for the practice or employer, including area code if available.

Enter the start date when you began working at this practice for the first work history entry.

Enter the end date when you stopped working at this practice for the first work history entry, or leave blank if still employed.

Enter the full name of the fourth professional, national, state, or international medical society or organization of which you are a member or applicant.

Check this box if you are an applicant (not a full member) of the fourth organization listed on the Organization Name row.

Check this box if you are a current member of the fourth organization listed on the Organization Name row.

Enter the group's Medicare Provider Transaction Access Number (PTAN) or UPIN as assigned by Medicare or the payer; include any letters or numbers exactly as issued.

Enter the group's assigned National Provider Identifier (NPI).

Enter the full mailing street address for the Healthcare Organization's Credentialing Department (street address, P.O. box, suite or floor).

Enter the city for the Healthcare Organization's Credentialing Department mailing address.

Enter the state or province for the Credentialing Department mailing address (preferably the two-letter state abbreviation).

Enter the postal ZIP or ZIP+4 code for the Healthcare Organization's Credentialing Department mailing address.

Enter the full name of the healthcare organization to which this addendum is being submitted. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if you do not want to be designated or listed as an HIV/AIDS specialist and do not wish to be identified for referrals or the Provider Directory as such.

Check this box if you want to be designated as an HIV/AIDS specialist and you meet one of the listed qualification criteria (for example credentialed by the AAHIVM or board certified/Certificate of Added Qualification in HIV Medicine).

Check this box if you hold the HIV Specialist credential issued by the American Academy of HIV Medicine. Fill only if 'Yes, I do wish to be designated as an HIV/AIDS specialist based on the below criteria' is 'Yes'.

Check this box if you are board certified in HIV Medicine or have earned a Certificate of Added Qualification in HIV Medicine from a member board of the American Board of Medical Specialties. Fill only if 'Yes, I do wish to be designated as an HIV/AIDS specialist based on the below criteria' is 'Yes'.

Check this box if you are board certified in Infectious Disease by an ABMS member board and, in the immediately preceding 12 months, have clinically managed at least 25 HIV-infected patients and completed a minimum of 15 hours of category 1 HIV-related continuing medical education (including at least 5 hours related to antiretroviral therapy). Fill only if 'Yes, I do wish to be designated as an HIV/AIDS specialist based on the below criteria' is 'Yes'.

Check this box if in the immediately preceding 24 months you have clinically managed at least 20 HIV-infected patients AND, in the immediately preceding 12 months, you have either obtained board certification/re-certification in Infectious Disease from an ABMS member board or completed at least 30 hours of category 1 HIV-related continuing medical education. Fill only if 'Yes, I do wish to be designated as an HIV/AIDS specialist based on the below criteria' is 'Yes'.

Enter the practitioner's full home mailing address including street number, apartment or unit number, and/or PO Box as applicable.

Enter the city of the practitioner's home mailing address.

Enter the state or province for the home mailing address, preferably using the standard two-letter abbreviation (e.g., CA).

Enter the ZIP or postal code for the home mailing address, including the ZIP+4 extension if available.

Check this box if the incident occurred at a hospital. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the incident occurred in your office. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the incident occurred at another doctor's office. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the incident occurred at a surgery center. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the incident occurred at a location not listed and specify that location in the adjacent text field. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the specific location where the incident occurred when 'Other' is selected (e.g., clinic/office name, department, room or brief address description). Fill only if 'Other (specify)' is 'Yes'.

Check this box if you intend to serve as a Primary Care Provider.

Check this box if you intend to serve as a Specialist.

Check this box if you intend to serve in Urgent Care.

Check this box if you intend to serve as a Hospitalist.

Check this box if you intend to serve in a Hospital-Based role.

Enter the full name of the internship institution or hospital where the PGY-1 was completed.

Provide the full name of the program director or primary contact for the PGY-1 internship.

Enter the street or mailing address of the PGY-1 institution, including suite or department if applicable.

Enter the city where the PGY-1 institution is located.

Enter the state or province for the PGY-1 institution (postal abbreviation is acceptable).

Enter the ZIP or postal code for the PGY-1 institution.

Provide the main telephone number for the PGY-1 program or institution, including area code and extension if applicable.

Provide the fax number for the PGY-1 program or institution, if available.

Enter the website URL for the PGY-1 program or institution, if applicable.

Describe the type or specialty of the PGY-1 internship (for example, 'Internal Medicine internship').

Enter the start date for the PGY-1 internship.

Enter the end date for the PGY-1 internship.

Check this box if you successfully completed the Internship/PGY-1 program.

Check this box if you did not successfully complete the Internship/PGY-1 program and will provide an explanation on a separate sheet.

Enter the languages spoken by your office staff (e.g., front desk, medical assistants), listing each language separated by commas.

Enter the languages spoken by the primary provider(s) at this location, listing each language separated by commas.

Enter the state abbreviation and your driver's license number exactly as shown on your license (include both the issuing state and the license number).

Enter your full Social Security Number as a continuous string of digits or with the hyphens, matching how you normally provide it for official records.

Check this box if the applicant's legal gender is male.

Check this box if the applicant's legal gender is female.

Check this box if there was an insurance company or other liability protection company/organization providing coverage or defense for the lawsuit or arbitration action. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if there was no insurance company or other liability protection company/organization providing coverage or defense for the lawsuit or arbitration action. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the name of the insurance or liability protection company (or organization) that provided coverage/defense and include the contact person, phone number, location, and the carrier's claim identification number or other identifying details for that company. Fill only if 'Liability coverage - Yes' is 'Yes'.

Enter the full mailing address for this practice only if it differs from the practice address, including street number and name, suite or unit (if any), city, state/province, and ZIP/postal code.

Enter the full name of the medical school or professional education program attended.

Enter the degree awarded by the listed school (for example: MD, DO, PA-C, RN).

Enter the graduation date from the listed medical or professional school.

Enter the mailing/street address for the medical or professional school, including apartment or PO box if applicable.

Enter the school's website or URL if one is available.

Enter the city in which the listed school is located.

Enter the state or province where the listed school is located (use postal abbreviation if required).

Enter the ZIP or postal code for the school's mailing address.

Enter the phone number for the school's registrar, including area code and extension if applicable.

Provide a written explanation for not having hospital privileges and describe your continuity of care plan, including how patients will be admitted or covered (names of covering physicians or facilities, referral or admitting arrangements, and relevant contact information).

Full name of the office administrator or manager responsible for administrative matters at this practice.

Direct telephone number for the office administrator or manager, including area code and any extension if applicable.

Email address for the office administrator or manager used for official communications about the practice.

Fax number for the office administrator or manager, including area code and any international or area prefixes if required.

Check this box if the prior item/condition applies to the Primary office location.

Check this box if the prior item/condition applies to the Secondary office location.

Check this box if the prior item/condition applies to the Tertiary office location.

Check this box if the office is fully accessible to patients with mobility impairments (e.g., wheelchair ramps or lifts, wide doorways, accessible exam rooms and restrooms) without need for special arrangements.

Check this box if the office has some accessibility features but is not fully accessible to all mobility-impaired patients and may require accommodations or assistance for full access.

Check this box if the office has no physical accessibility features for mobility-impaired patients (no ramps, narrow doorways, inaccessible exam rooms/restrooms).

Enter the name or type of the first additional certification (for example, Fluoroscopy, ACLS, BLS, PALS, Radiography) as it should appear on your record.

Enter the license or certificate number associated with the first additional certification; include any letters or punctuation exactly as issued.

Enter the expiration date for the first additional certification.

Enter the name or type of the fourth additional certification (for example, ACLS, BLS, Fluoroscopy) as it appears on the certificate.

Enter the license or certificate number associated with the fourth certification, including any letters or dashes exactly as issued.

Enter the expiration date of the fourth certification.

Enter the name or type of the additional certification (for example, Fluoroscopy, ACLS, BLS, PALS) that applies to this entry.

Provide the license or certificate number assigned to the certification entered in this row.

Enter the expiration date of the certification listed in this row.

Enter the name or type of the third additional certification (for example, Fluoroscopy, ACLS, BLS, PALS) that you hold.

Enter the license or certificate number associated with the third certification exactly as it appears on the credential.

Enter the expiration date for the third certification.

Enter the name or two-letter postal abbreviation of the state that issued this additional medical license.

Enter the license number assigned by that state's medical board for this additional medical license.

Enter the date the additional state medical license was issued.

Enter the expiration date of the additional state medical license.

Enter the U.S. state or other issuing jurisdiction that issued the fourth other medical license (postal abbreviation or full name).

Enter the license number assigned by the issuing state or jurisdiction for the fourth other medical license.

Enter the date the fourth other state medical license was issued.

Enter the expiration date for the fourth other state medical license.

Enter the U.S. state (abbreviation or full name) that issued this additional medical license.

Enter the full medical license number assigned by the state medical board, including any letters, dashes, or other characters.

Enter the date on which this state medical license was issued.

Enter the date on which this state medical license will expire.

Enter the U.S. state or other jurisdiction that issued the third additional medical license.

Enter the license number assigned by that state's medical board for your third additional license.

Enter the date on which that state medical license was issued.

Enter the expiration date of that state medical license.

Enter the patient's full name (first and last, and middle if applicable) as it should appear on the record. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box when the patient's gender is male. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box when the patient's gender is female. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the patient's date of birth. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if you personally employ one or more physicians (do not include physicians employed by the medical group).

Check this box if you do not personally employ any physicians (do not include physicians employed by the medical group).

Check this box if the office has basic physical accessibility features (e.g., step-free entry, accessible restroom, and standard accommodations) allowing most people with mobility impairments to enter and use key facilities.

Check this box if the office has only limited accessibility (e.g., partial step-free access, narrow doorways, or restricted access to some areas) that may impede some people with disabilities.

Check this box if the office has no physical accessibility features and is not accessible to persons with mobility impairments.

Enter the full name of the physician assistant supervisor for this practice (first and last name). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the supervisor's medical/license number as assigned by the licensing board (include any letters, numbers, or dashes). Fill only if 'Employ Allied Health Professionals - Yes' is 'Yes'.

Enter the full name of the first physician you personally employ (e.g., last name, first name, middle initial as needed). Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Enter the California medical license number assigned to the first physician listed. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the first row has this practice as their primary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the first row has this practice as their secondary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the first row has this practice as their tertiary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Enter the full name of the physician listed on the second row (first/last and any professional suffix) exactly as you want it to appear on the record. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Enter the physician's California medical license number for the physician on the second row (include letters or leading zeros if present). Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician on the second row lists this practice as their Primary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician on the second row lists this practice as their Secondary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician on the second row lists this practice as their Tertiary practice. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Enter the full name of the physician for the third row (first and last name as you want it recorded). Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Enter the physician's California medical license number for the third row exactly as issued by the licensing board. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the third row practices at or is associated with your Primary office. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the third row practices at or is associated with your Secondary office. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the physician listed on the third row practices at or is associated with your Tertiary office. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if your practice accepts patients only within specific age ranges (i.e., there is any age-based limitation).

Check this box if your practice does not impose any age-based limitations on patients.

Enter the practice's age limitation (for example an age range, minimum or maximum age, or other age restriction) that applies if the practice is limited to certain ages. Fill only if 'Practice limited to certain ages — Yes' is 'Yes'.

Enter the full legal or doing-business-as name of your practice or clinic as it should appear on credentialing records.

If you work within a hospital, enter the name of your department or service line; leave blank if not hospital based. Fill only if 'Hospital Based' is 'Yes'.

Enter the practice's primary office telephone number, including area code and country code if applicable.

Enter the practice's fax number for the primary office, including area code and country code if applicable.

Enter the practice's website URL if applicable (include the full address, e.g., http:// or https:// or www.).

Enter the practice's pager number if available, including area code or service prefix as needed.

Check this box if your practice currently uses a practice management system or software.

Check this box if your practice does not use a practice management system or software.

Enter the name of the practice management system or software your office uses (leave blank if none). Fill only if 'Practice Management System/Software - Yes' is 'Yes'.

Enter your family or surname as it appears on professional or legal records. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter your given (first) name as used on professional or legal records. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter your middle name or middle initial, if any; leave blank if none. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the full name and mailing address of the prior hospital or institution for this affiliation, including street, city, state and ZIP as appropriate.

Provide the specific department, division, or unit within the institution where you held your affiliation.

Enter the month and year when this affiliation began.

Enter the month and year when this affiliation ended, or leave blank if it is ongoing.

Briefly state the reason you left this affiliation (for example: relocation, end of appointment, termination, retirement, etc.).

Enter the full name and mailing address of the institution or facility for your second previous affiliation.

Enter the department, division, or unit name where you worked at this affiliation.

Enter the start date of your tenure at this affiliation.

Enter the end date of your tenure at this affiliation.

Provide a brief explanation of why you left this affiliation (for example, resignation, contract ended, relocation, or termination).

Check this box if your primary practice location is the mailing address to be used for correspondence.

Check this box if your secondary practice location is the mailing address to be used for correspondence.

Check this box if your tertiary practice location is the mailing address to be used for correspondence.

Check this box if the mailing address is for a practice location other than your primary, secondary, or tertiary locations (and provide that address below).

Enter the primary office street address including number, street name and any suite or room information.

Enter the city where your primary office is located.

Enter the state or territory of your primary office (abbreviation or full name).

Enter the ZIP or postal code for your primary office.

Enter the regular office hours for the primary practice, including days and opening/closing times (for example, Mon–Fri 9:00 AM–5:00 PM).

List the languages spoken by office staff that patients can use for communication, separated by commas.

List the languages spoken by the provider(s) at this practice that patients can use for clinical encounters, separated by commas.

Enter the group's Medicare PTAN or UPIN identifier as assigned by Medicare or the applicable payer.

Enter the group's National Provider Identifier (NPI).

Check this box if the practice is a solo practice operated by a single provider.

Check this box if the practice is a group practice with multiple providers sharing the practice.

Check this box if the practice is a group composed of providers all in the same medical specialty.

Check this box if the practice is a group that includes providers from multiple different specialties.

Check this box if the practice operates as an urgent care facility.

Check this box if the trainee/applicant successfully completed the program.

Check this box if the trainee/applicant did not successfully complete the program (if No, provide an explanation on a separate sheet).

Check this box if you have provided or attached the provider's National Provider Identifier (NPI) number.

Check this box if you have included a copy of the Medi‑Cal acceptance letter or have provided the provider's Medi‑Cal number.

Check this box if you have included a copy of the Medicare certification letter or have provided the provider's Medicare number.

Check this box if you are requesting or declaring a specialty for the provider and have entered the requested specialty.

Enter the provider's 10-digit National Provider Identifier (NPI) as issued by the appropriate authority.

Enter the provider's Medi‑Cal or Medicaid identification number used for billing or enrollment.

Enter the provider's Individual Medicare Provider Transaction Access Number (PTAN) assigned by Medicare.

Check this box if you are currently a Certified Qualified Medical Examiner (QME) of the State Industrial Medical Council.

Check this box if you are not a Certified Qualified Medical Examiner (QME) of the State Industrial Medical Council.

Check this box if you have ever rendered professional medical services as an employee of a staff-model HMO, an entity insured by the federal government (e.g., military or Federally Qualified Health Center), or an academic institution (and provide details if, within the past seven years, you were named as a defendant in a lawsuit).

Check this box if you have never rendered professional medical services as an employee of a staff-model HMO, a federally insured entity, or an academic institution and you have not been named as a defendant in a related lawsuit within the past seven years.

Check this box if, in the past seven (7) years, you have been named as a defendant in a lawsuit arising from rendering professional medical services as an employee of a staff-model HMO, a federal/insured entity (e.g., military or Federally Qualified Health Center), or an academic institution (whether or not the matter was later dismissed). Fill only if '13. Professional Medical Services — Yes' is 'Yes'.

Check this box if you have NOT been named as a defendant in any lawsuit in the past seven (7) years related to rendering professional medical services as described in the question. Fill only if '13. Professional Medical Services — Yes' is 'Yes'.

Check this box if you are currently engaged in the illegal use of drugs or currently have a chemical or substance abuse dependency.

Check this box if you are not currently engaged in illegal drug use and do not have a chemical or substance abuse dependency.

Check this box if within the last three years your membership, privileges, participation or affiliation with any healthcare organization was terminated, suspended, restricted, or you took a leave of absence for reasons related to alcohol or drug abuse or dependency.

Check this box if none of the events described in Question 15 occurred within the last three years (no termination, suspension, restriction, or leave of absence for alcohol- or drug-related reasons).

Enter your relationship to the patient in this case (for example: attending physician, surgeon assistant, consultant, nurse, etc.). Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Briefly state the specific allegation or cause of the claim being made against you in this lawsuit or arbitration. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' OR 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the full name of the institution where the residency or fellowship was completed.

Enter the name of the program director responsible for this residency or fellowship.

Enter the street address of the institution (building, suite, P.O. box, etc.).

Enter the city where the institution or training program is located.

Enter the state or province (abbreviation or full name) where the institution is located.

Enter the ZIP or postal code for the institution's address.

Enter the primary telephone number for the institution or program, including area code and extension if applicable.

Enter the fax number for the institution or program, including area code if applicable.

Enter the institution or program's website URL, if applicable.

Enter the type of training (for example, Residency, Fellowship, or other postgraduate training).

Enter the medical specialty or subspecialty of the training program.

Enter the start date of the training program.

Enter the end date of the training program.

Check this box if you successfully completed the first listed residency/fellowship program.

Check this box if you did not successfully complete the first listed residency/fellowship program (and provide an explanation on a separate sheet).

Enter the full name of the institution where the second residency or fellowship was completed.

Enter the full name of the program director or primary contact for this residency/fellowship.

Enter the complete street address of the institution for this residency/fellowship, including suite or unit number if applicable.

Enter the city where the residency/fellowship institution is located.

Enter the state or province where the residency/fellowship institution is located.

Enter the postal ZIP or postal code for the institution's address.

Enter the main telephone number for the institution or program contact, including area code.

Enter the fax number for the institution or program if available.

Enter the institution or program's website URL, if applicable.

Enter the type or level of training completed at this program (for example, Residency or Fellowship).

Enter the medical specialty or subspecialty of the training program.

Enter the start date of the residency or fellowship program.

Enter the end or completion date of the residency or fellowship program.

Check this box if you successfully completed the residency/fellowship program for the second (this) entry.

Check this box if you did not successfully complete the residency/fellowship program for the second (this) entry (and provide an explanation on a separate sheet).

Enter the full name and mailing address of the second affiliation, including institution, street address, city and country.

Enter the department, division, or unit at the second affiliation where you worked or were appointed.

Enter the month and year when your affiliation with this organization began.

Enter the month and year when your affiliation with this organization ended or indicate if it is ongoing.

Provide a brief explanation of the reason you left or stopped the affiliation with this organization.

Enter the full name of the second international, state, or national medical society or other professional organization of which you are a member or an applicant.

Check this box if you are an applicant for membership in the second organization listed on the form.

Check this box if you are a current member of the second organization listed on the form.

Enter the full name (first and last) of the second peer reference.

Enter the peer's medical or professional specialty (for example, cardiology or internal medicine).

Enter the street or office address for the second reference's place of practice.

Enter the city where the second reference's office is located.

Enter the state or province for the second reference's address (abbreviation or full name).

Enter the ZIP or postal code for the second reference's address.

Enter the reference's telephone number, including area code and country code if applicable.

Enter the reference's fax number for the office, including area code if applicable.

Enter the reference's professional email address for contact.

Enter the full name of the second professional liability insurance carrier.

Enter the policy number assigned to this insurance by the second carrier.

Enter the street or mailing address for the second carrier.

Enter the city for the second carrier's address.

Enter the state (abbreviation or full name) for the second carrier's address.

Enter the postal ZIP or postal code for the second carrier's address.

Enter the primary telephone number to contact the second carrier about this policy.

Enter the fax number for the second carrier, if available.

Enter the second carrier's website URL, if applicable.

Enter a contact email address for the second carrier or its policy administrator.

Check this box if the second listed professional liability carrier does provide tail coverage.

Check this box if the second listed professional liability carrier does not provide tail coverage.

Enter the per-claim coverage limit provided by this policy.

Enter the date the policy originally became effective.

Enter the date the policy is scheduled to expire.

Enter the total aggregate coverage limit for the policy.

Enter the name of the employer, practice, or organization for the second work history entry.

Enter the full name of the primary contact person at this practice or organization.

Enter the street address for this practice, including suite or unit number if applicable.

Enter the city where this practice or organization is located.

Enter the state or province for this practice (use the standard abbreviation if available).

Enter the postal ZIP or postal code for this practice's address.

Enter the main telephone number for this practice, including area and country code if applicable.

Enter the fax number for this practice, including area and country code if applicable.

Enter the start date for this position at the practice.

Enter the end date for this position at the practice, or indicate that it is the current position if still employed.

Check this box if the secondary office has basic physical accessibility features (for example, accessible entrance and facilities) and is generally accessible to patients with mobility limitations.

Check this box if the secondary office has only limited accessibility (some barriers exist or only partial access for patients with mobility limitations).

Check this box if the secondary office has no physical accessibility accommodations and is not accessible to patients with mobility limitations.

Enter the full name of the secondary practice or facility; leave blank if not applicable.

Enter the department or unit name for the secondary practice if it is hospital-based. Fill only if 'Your intent is to serve as a(n)' is 'Hospital Based'.

Enter the street address of the secondary office, including suite or floor information if applicable.

Enter the city in which the secondary office is located.

Enter the state (abbreviation or full name) where the secondary office is located.

Enter the ZIP or postal code for the secondary office.

Enter the main telephone number for the secondary office, including area code and extension if applicable.

Enter the fax number for the secondary office, including area code.

Enter the secondary practice's website URL or web address, if available.

Enter the full name of the secondary practice's office administrator or manager (first and last name).

Enter the telephone number for the secondary practice office administrator/manager, including area code.

Enter the business email address for the secondary practice office administrator/manager.

Enter the fax number for the secondary practice office administrator/manager, including area code.

Enter the secondary practice's regular office hours for this location (for example, Mon–Fri 8:00 AM–5:00 PM).

List the languages spoken by staff at the secondary practice location, separated by commas if more than one.

List the languages spoken by the provider(s) at the secondary practice location, separated by commas if more than one.

Enter the group's Medicare PTAN or UPIN associated with this secondary practice, if applicable.

Enter the group's National Provider Identifier (NPI) for the secondary practice.

Enter the secondary practice's federal tax identification number (EIN) assigned to this practice.

Enter the legal name or business name that is registered with the federal tax ID for the secondary practice.

Check this box if the secondary practice location is a solo practice (an independently operated office with a single practitioner).

Check this box if the secondary practice location is part of a group practice (multiple providers practicing together under the same practice).

Check this box if the secondary practice location is a single-specialty group (the group practices only one medical specialty).

Check this box if the secondary practice location is a multi-specialty group (the group includes providers from multiple medical specialties).

Check this box if the secondary practice location is an urgent care facility.

Enter the practitioner’s primary medical specialty (e.g., Family Medicine, Internal Medicine, Cardiology) as a short text label.

List any relevant subspecialties or areas of focused practice for the practitioner, separated by commas if more than one (e.g., Interventional Cardiology, Pediatric Cardiology).

Check this box if the lawsuit or arbitration is still in progress and has not been resolved. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if a judgment was rendered and a payment was made on your behalf (enter the amount in the adjacent field). Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if a judgment was rendered in the case but you were found not liable. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the matter was settled and a payment was made on your behalf (enter the amount paid in the adjacent field). Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Check this box if the lawsuit or arbitration was settled or dismissed without a judgment and no payment was made on your behalf. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Provide a complete narrative describing the circumstances that gave rise to the action, including the condition and diagnosis at the time, dates and description of treatment you rendered, the patient’s condition after treatment, and note that you may attach additional sheets if more space is needed. Fill only if 'Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases?' is 'Yes' or 'Are there any professional liability lawsuits/arbitrations against you that have been dismissed or currently pending?' is 'Yes'.

Enter the regular office hours for the tertiary location (e.g., days and times such as "Mon–Fri 9:00 AM–5:00 PM"), specifying any variations or notes about availability.

Enter the full name of the tertiary practice location, or leave blank if not applicable.

Enter the department or unit name for the tertiary practice if it is hospital-based. Fill only if 'Your intent is to serve as a(n)' is 'Hospital Based'.

Enter the street address for the tertiary office, including suite or floor information if applicable.

Enter the city where the tertiary office is located.

Enter the state or territory for the tertiary office (use the standard two-letter abbreviation if applicable).

Enter the postal ZIP or ZIP+4 code for the tertiary office address.

Enter the primary telephone number for the tertiary office, including area code.

Enter the fax number for the tertiary office, including area code, if available.

Enter the website URL for the tertiary practice location, if one exists.

Enter the full name (first and last) of the tertiary practice's office administrator or manager.

Enter the primary telephone number for the tertiary office administrator or manager, including area code.

Enter the email address for the tertiary office administrator or manager.

Enter the fax number for the tertiary office administrator or manager, including area code.

Enter the federal tax identification number (EIN) for the tertiary practice associated with this office.

Provide the full name (business or individual) that is registered with the federal tax ID for the tertiary practice.

Enter the full name and mailing address of the organization or institution for this third affiliation, including street, city, state/province and country.

Provide the specific department, division, or unit within the affiliation where you worked or were assigned.

Enter the start date of your affiliation at this organization.

Enter the end date of your affiliation at this organization or leave blank if it is ongoing.

Briefly state the reason you left or expect to leave this affiliation.

Enter the full name of the third international, state, or national medical society or professional organization of which you are a member or applicant.

Check this box if you are an applicant for membership in the third-listed organization (you have applied but are not currently a member).

Check this box if you are a current member of the third-listed organization.

Enter the full name of the third professional reference, including title and credentials if applicable.

Enter the reference's medical specialty or professional field (for example, Cardiology or Internal Medicine).

Enter the street mailing address for the reference, including suite or office number if applicable.

Enter the city for the reference's mailing address.

Enter the state or province for the reference's mailing address (use the standard postal abbreviation or full name as preferred).

Enter the postal ZIP or other postal code for the reference's address.

Enter the reference's daytime telephone number, including area code and extension if applicable.

Enter the reference's fax number, including area code if applicable.

Enter the reference's professional email address.

Enter the full name of the third professional liability insurance carrier.

Enter the policy number assigned to this carrier's insurance policy.

Enter the street address for the third carrier's office listed for this policy.

Enter the city for the carrier address associated with this policy.

Enter the state for the carrier address associated with this policy.

Enter the ZIP or postal code for the carrier address associated with this policy.

Enter the primary telephone number for the carrier or policy contact.

Enter the fax number for the carrier or policy contact, if available.

Enter the carrier's website URL if applicable.

Enter the email address for the carrier or the policy contact.

Check this box if the third listed professional liability carrier provides tail coverage (select Yes).

Check this box if the third listed professional liability carrier does not provide tail coverage (select No).

Enter the per-claim coverage amount for this policy.

Enter the original effective date of this policy.

Enter the expiration date of this policy.

Enter the aggregate coverage amount for this policy.

Enter the name of the third employer, practice, or organization where you worked (e.g., clinic or hospital name).

Enter the full name of a contact person at this practice (supervisor or administrator) who can verify your employment.

Enter the street address of this practice, including suite or unit number if applicable.

Enter the city where this practice is located.

Enter the state or province where the practice is located (use the standard two-letter abbreviation or full name).

Enter the postal ZIP or postal code for the practice's address.

Enter the practice's main telephone number, including area code and any extension if applicable.

Enter the practice's fax number, including area code if applicable.

Enter the start date when you began working at this practice.

Enter the end date when you stopped working at this practice, or leave blank if still employed.

Full name of the training program director or primary program contact.

Official name of the institution or organization that provided the training program.

Street address of the institution, including building number, suite, or unit as applicable.

City where the institution is located.

State or province (abbreviation or full name) where the institution is located.

Postal ZIP or postal code for the institution's address.

Main telephone number for the training program or institution, including area code and any country code or extension if needed.

Fax number for the training program or institution, including area code if applicable.

Website URL for the training program or institution, if available; leave blank if none.

Enter the name or category of the training program (for example, Internship, Residency, Fellowship or Course).

Enter the medical specialty or primary focus area of the training program (for example, Internal Medicine, Pediatrics, Surgery).

Enter the start date of this training program.

Enter the end or completion date of this training program.

Check this box if the office is a solo practice operated by a single practitioner (not part of a larger group).

Check this box if the office is part of a general group practice with multiple practitioners under the same practice.

Check this box if the practice is a group composed of providers all practicing the same medical specialty.

Check this box if the practice is a group that includes providers from multiple different specialties.

Check this box if the facility operates as an urgent care center providing immediate, walk-in or non-scheduled care.

Check this box if the information or item on the form applies to your Primary office/practice location. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the information or item on the form applies to your Secondary office/practice location. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.

Check this box if the information or item on the form applies to your Tertiary office/practice location. Fill only if 'Personally Employ Physicians — Yes' is 'Yes'.