Oregon Practitioner Credentialing Application (including Attachment A: Professional Liability Action Detail) Completed Form Examples and Samples
Find comprehensive, filled-out examples and samples of the Oregon Practitioner Credentialing Application. Our detailed guide includes a correctly completed Attachment A: Professional Liability Action Detail, helping you navigate the credentialing process with confidence. View a realistic sample to ensure your submission is accurate and complete.
Oregon Practitioner Credentialing Application Example: Family Physician
How this form was filled:
This is a detailed example of a filled-out Oregon Practitioner Credentialing Application for a fictional family physician, Dr. Emily Carter. It showcases the complete entry of professional details, licensure, education, and work history. Crucially, it includes a correctly completed Attachment A to disclose a professional liability action, providing a comprehensive guide for applicants.
Information used to fill out the document:
- Full Name: Dr. Emily Claire Carter, MD
- Primary Specialty: Family Medicine
- NPI Number: 1234567890
- Oregon Medical License: MD198765
- License Original Issue Date: 06/15/2023
- DEA Number: EC9876543
- Medical School: Oregon Health & Science University School of Medicine
- Medical School Graduation Date: 06/01/2018
- Residency Program: Family Medicine Residency, OHSU Cascades East Family Medicine Center
- Residency Completion Date: 06/30/2021
- Board Certification: American Board of Family Medicine
- Certification Date: 10/25/2021
- Current Practice Name: Portland Family Health Clinic
- Current Malpractice Insurance Carrier: The Doctors Company
- Policy Number: TDC-555-1212
- Policy Period: 07/01/2025 - 06/30/2026
- Claim Allegation (Attachment A): Failure to timely diagnose a fracture
- Date of Incident (Attachment A): 03/10/2024
- Date Claim Filed (Attachment A): 08/22/2024
- Claim Status (Attachment A): Closed
- Resolution (Attachment A): Settled by malpractice carrier without admission of liability.
- Settlement Amount (Attachment A): $75,000
- Date of Final Action/Closure (Attachment A): 01/15/2026
- Application Signature Date: 05/20/2026
What this filled form sample shows:
- Thorough completion of all practitioner demographic and contact information sections.
- Detailed listing of education, post-graduate training, and board certification with current dates.
- Accurate inclusion of all required identifying numbers: NPI, DEA, and State Medical License.
- A correctly filled-out Attachment A: Professional Liability Action Detail, demonstrating transparent disclosure of a past claim.
- Complete five-year work history and professional liability insurance coverage details.
Form specifications and details:
| Form Name: | Oregon Practitioner Credentialing Application |
| Included Attachments: | Attachment A: Professional Liability Action Detail |
| Use Case: | Credentialing application for a medical doctor (MD) in Family Medicine with one reportable professional liability claim. |
| Jurisdiction: | Oregon, USA |
| Fictional Applicant: | Dr. Emily Carter, MD |
| Categories: | ACH forms, credentialing forms, practitioner forms |
| Created: | February 05, 2026 09:11 PM |