Oregon Practitioner Credentialing Application (including Attachment A: Professional Liability Action Detail) Instructions

Enter any additional clinical practice specialties you have beyond your primary clinical specialty.

Enter your initials to indicate you have reviewed and certified the information on this page.

Enter the date on which you initialed this page.

Check this box if you have no hospital or other health care facility affiliation applications currently in process.

Check this box if you attest that you have no physical, mental health, chemical dependency, alcohol, or other substance issues that currently affect your ability to practice.

Check this box if the answer to Attestation Question A about any licensure/certification/registration (including DEA or narcotic registration) denial, limitation, suspension, revocation, non-renewal, relinquishment, probationary conditions, corrective action, reprimand, or pending action is yes.

Check this box if the answer to Attestation Question A about any licensure/certification/registration (including DEA or narcotic registration) denial, limitation, suspension, revocation, non-renewal, relinquishment, probationary conditions, corrective action, reprimand, or pending action is no.

Check this box if you have ever been suspended, fined, disciplined, sanctioned, restricted, or excluded by Medicare, Medicaid, or any public program, or if such an action is pending or under review.

Check this box if you have never been suspended, fined, disciplined, sanctioned, restricted, or excluded by Medicare, Medicaid, or any public program, and no such action is pending or under review.

Check this box if you have ever been denied clinical privileges, membership, or contractual participation by a health care related organization, or if such privileges/participation/employment have ever been placed on probation/suspended/restricted/revoked/relinquished/not renewed, or if any such action is pending or under review.

Check this box if none of the situations described in Attestation Question C have ever happened to you and no such action is pending or under review.

Check this box if you have ever surrendered clinical privileges, accepted restrictions on privileges, had contractual participation or employment terminated, taken a leave of absence, been committed to retraining, or resigned from a health care organization while under investigation or potential review.

Check this box if none of the listed events have ever occurred (no surrender/restrictions/termination/leave/retraining/resignation while under investigation or potential review).

Check this box if an application for clinical privileges, appointment, membership, employment, or participation in any health care related organization was ever withdrawn at your request before the organization’s final action.

Check this box if no application for clinical privileges, appointment, membership, employment, or participation in any health care related organization has ever been withdrawn at your request before the organization’s final action.

Check this box if you answer YES to Attestation Question F about any professional organization membership or fellowship ever being revoked, denied, limited, relinquished, not renewed under investigation, or if such action is pending or under review.

Check this box if you answer NO to Attestation Question F (none of the listed professional organization membership or fellowship actions have occurred and none are pending or under review).

Check this box if you have ever voluntarily or involuntarily left or been discharged from any education or training program related to your current licensure or certification.

Check this box if you have never voluntarily or involuntarily left or been discharged from any education or training program related to your current licensure or certification.

Check this box if you have ever had a board certification revoked.

Check this box if you have never had a board certification revoked.

Check this box if you have ever been the subject of any reports to a state or federal data bank or to a state licensing or disciplinary entity.

Check this box if you have never been the subject of any reports to a state or federal data bank or to a state licensing or disciplinary entity.

Check this box if you have ever been charged with a criminal violation (felony or misdemeanor).

Check this box if you have never been charged with a criminal violation (felony or misdemeanor).

Check this box if you presently use any illegal drugs.

Check this box if you do not presently use any illegal drugs.

Check this box if you are unable to perform any required services/clinical privileges under the participating practitioner agreement/hospital appointment, with or without reasonable accommodation.

Check this box if you are not unable to perform the required services/clinical privileges under the participating practitioner agreement/hospital appointment.

Check this box if any professional liability claims or lawsuits have ever been closed and/or filed against you.

Check this box if no professional liability claims or lawsuits have ever been closed and/or filed against you.

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 professional liability insurance.

Check this box if your professional liability insurance has never been terminated, not renewed, restricted, modified, and you have never been denied professional liability insurance.

Enter your full legal name as the practitioner/applicant providing this authorization.

Enter the date you are signing and submitting this authorization and release form.

List the health care related organization(s) to whom you grant permission to receive the credentialing information from this application.

Enter the month of your birth.

Enter the day of the month you were born.

Enter the year you were born.

Enter the city and state/province (and country if outside the U.S.) where you were born.

Describe your intent to obtain board certification (if not currently certified) and list the dates of any previous certification testing and/or planned future testing. Fill only if 'Does not apply' is 'No'.

Check this box if the Board Certification/Recertification section does not apply to you (e.g., for licensure you have no board certifications to report).

Enter the date you signed the certification statement. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter your country of citizenship.

Enter your Social Security number.

Check this box if your gender is male.

Check this box if your gender is female.

Check this box if you use X as your gender marker.

Check this box if your clinical practice is full time.

Check this box if your clinical practice is part time.

Check this box if you practice as a locum tenens or in a temporary clinical position.

Check this box if you provide clinical services via telemedicine/telehealth.

Check this box if your clinical practice category is not listed and provide an explanation in the space provided.

If you selected “Other” under clinical practice category, enter a brief explanation of the clinical practice category you are reporting. Fill only if 'Other (explain)' is 'Yes'.

Check this box if you have no fellowships, preceptorships, or other clinical training programs to report in this section.

Check this box if the Continuing Medical Education (CME) section does not apply to you and you have no CME activities to report for the past two years.

Explain your plan for ensuring continuity of care for patients who require hospital admission when you do not have admitting privileges at any listed facility. Fill only if 'Admitting privileges: No', 'Admitting privileges – No', 'Admitting privileges at this facility — No', 'Admitting privileges at this facility – No' are 'Yes' (all fields).

Enter your Controlled Substance Registration (CSR) number, if applicable.

Enter the month of issue for the Controlled Substance Registration (CSR).

Enter the day of issue for the Controlled Substance Registration (CSR).

Enter the year of issue for the Controlled Substance Registration (CSR).

Enter the person's professional credentials (e.g., degrees, licenses, certifications, or titles).

Describe your professional relationship to the person (e.g., supervisor, colleague, treating provider, or consultant).

Check this box if you have no current hospital or other health care facility affiliations to report.

Enter the name of your current professional liability insurance carrier or coverage provider.

Enter the policy number for your current professional liability insurance coverage.

Check this box if your current professional liability insurance policy is a claims-made policy.

Check this box if your current professional liability insurance policy is an occurrence policy.

Enter the name of your local contact person for this insurance policy.

Enter the mailing address for the insurance carrier or local contact.

Enter the area code for the insurance contact’s telephone number.

Enter the first three digits of the insurance contact’s telephone number after the area code.

Enter the last four digits of the insurance contact’s telephone number.

Enter the extension for the insurance contact’s telephone number, if applicable.

Enter the area code for the fax number, if available.

Enter the first three digits of the fax number after the area code, if available.

Enter the last four digits of the fax number, if available.

Enter the policy’s per-claim limit of liability amount.

Enter the policy’s aggregate coverage amount.

Enter the email address for the insurance contact, if available.

Enter the month the policy became effective.

Enter the day of the month the policy became effective.

Enter the year the policy became effective.

Enter the month of the policy retroactive date, if applicable.

Enter the day of the month of the policy retroactive date, if applicable.

Enter the year of the policy retroactive date, if applicable.

Enter the month the policy expires.

Enter the day of the month the policy expires.

Enter the year the policy expires.

Enter your Drug Enforcement Administration (DEA) registration number, if you have one.

Enter the month of the issue date for the DEA registration.

Enter the day of the issue date for the DEA registration.

Enter the year of the issue date for the DEA registration.

Enter the month of the expiration date for the DEA registration.

Enter the day of the expiration date for the DEA registration.

Enter the year of the expiration date for the DEA registration.

Enter your Educational Commission for Foreign Medical Graduates (ECFMG) identification number, if applicable.

Enter the month your ECFMG number or certificate was issued.

Enter the year your ECFMG number or certificate was issued.

Enter your primary email address where you can be contacted regarding this credentialing application.

Enter your email address, if available.

Enter the area code portion of the fax number.

Enter the next three digits of the fax number.

Enter the last four digits of the fax number.

Enter the name or title of the fifth continuing medical education (CME) activity you completed. Fill only if 'Does not apply' is 'No'.

Enter the month in which you attended the fifth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year in which you attended the fifth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the number of CME credit hours earned for the fifth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the full name of the fifth practitioner who provides call coverage for your patients when you are unavailable.

Enter the medical specialty of the fifth practitioner listed as providing call coverage.

Enter the name of the health care facility for this application in process. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility phone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the facility phone number after the area code. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the facility fax number after the area code, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the facility’s complete mailing address for this application in process. Fill only if 'Does not apply' is 'No'.

Enter your current status with this facility application (e.g., active, courtesy, provisional, allied health, etc.). Fill only if 'Does not apply' is 'No'.

Enter the month when the application was submitted. Fill only if 'Does not apply' is 'No'.

Enter the day of the month when the application was submitted. Fill only if 'Does not apply' is 'No'.

Enter the year when the application was submitted. Fill only if 'Does not apply' is 'No'.

Enter the name of the board that issued this certification. Fill only if 'Does not apply' is 'No'.

Enter the certification number assigned by the issuing board, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the specialty area for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the month you were certified or recertified for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the year you were certified or recertified for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the month this certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the year this certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the city where the first clinical training program institution is located. Fill only if 'Does not apply' is 'No'.

Enter the state where the first clinical training program institution is located. Fill only if 'Does not apply' is 'No'.

Enter the ZIP code for the address of the first clinical training program institution. Fill only if 'Does not apply' is 'No'.

Enter the email address for the contact person at the first clinical training program institution. Fill only if 'Does not apply' is 'No'.

Check this box if you completed this first clinical training program. Fill only if 'Does not apply' is 'No'.

Check this box if you did not complete this first clinical training program (and provide an explanation on a separate sheet if required). Fill only if 'Does not apply' is 'No'.

Enter the month when this clinical training program began. Fill only if 'Does not apply' is 'No'.

Enter the year when this clinical training program began. Fill only if 'Does not apply' is 'No'.

Enter the month when this clinical training program ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this clinical training program ended. Fill only if 'Does not apply' is 'No'.

Enter the month you completed this clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the year you completed this clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the full name of the institution and its street address for the first clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the specialty for this first clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the area code portion of the phone number for this first clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the phone number for this first clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the phone number for this first clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the area code portion of the fax number for this first clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the fax number for this first clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the fax number for this first clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the name or title of the first continuing medical education (CME) activity for which you received credit. Fill only if 'Does not apply' is 'No'.

Enter the month in which you attended the first CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year in which you attended the first CME activity. Fill only if 'Does not apply' is 'No'.

Enter the number of CME credit hours you received for the first CME activity. Fill only if 'Does not apply' is 'No'.

Check this box if you have admitting privileges at the listed facility. Fill only if 'Does not apply' is 'No'.

Check this box if you do not have admitting privileges at the listed facility. Fill only if 'Does not apply' is 'No'.

Enter the name of your current affiliated health care facility. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the prefix (middle three digits) for the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits for the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility’s fax number. Fill only if 'Does not apply' is 'No'.

Enter the prefix (middle three digits) for the facility’s fax number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits for the facility’s fax number. Fill only if 'Does not apply' is 'No'.

Enter the facility’s complete mailing address. Fill only if 'Does not apply' is 'No'.

Enter your status at this facility (e.g., active, courtesy, provisional, allied health). Fill only if 'Does not apply' is 'No'.

Enter the month of your appointment/affiliation start date at this facility. Fill only if 'Does not apply' is 'No'.

Enter the day of your appointment/affiliation start date at this facility. Fill only if 'Does not apply' is 'No'.

Enter the year of your appointment/affiliation start date at this facility. Fill only if 'Does not apply' is 'No'.

Enter the email address for the facility contact. Fill only if 'Does not apply' is 'No'.

Enter the name of your professional liability insurance carrier. Fill only if 'Does not apply' is 'No'.

Enter the name of the certification (e.g., ACLS, BLS, ATLS) for this first certification entry.

Enter the certificate or license number associated with this certification.

Enter the month in which this certification was issued or obtained.

Enter the year in which this certification was issued or obtained.

Enter the month in which this certification expires.

Enter the year in which this certification expires.

Enter the state or country that issued this license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the license, registration, or certificate identification number issued by the state/country. Fill only if 'Does not apply' is 'No'.

Enter the type of license, registration, or certificate held in the other state/country. Fill only if 'Does not apply' is 'No'.

Enter the year you originally obtained this license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the day of the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year you relinquished or surrendered this license, registration, or certificate, if applicable. Fill only if 'Does not apply' is 'No'.

Provide the reason related to this license, registration, or certificate (for example, why it was relinquished or any relevant status details). Fill only if 'Does not apply' is 'No'.

Enter the full name of the first peer reference.

Enter the clinical specialty of the first peer reference.

Enter the complete mailing address for the first peer reference, including location name and department if applicable.

Enter the professional credentials of the first peer reference (e.g., MD, DO, RN).

Describe your professional relationship with the first peer reference (e.g., colleague, supervisor, department peer).

Enter the area code of the first peer reference’s telephone number.

Enter the next three digits (prefix) of the first peer reference’s telephone number.

Enter the last four digits (line number) of the first peer reference’s telephone number.

Enter the telephone extension for the first peer reference, if applicable.

Enter the area code of the first peer reference’s fax number.

Enter the next three digits (prefix) of the first peer reference’s fax number.

Enter the last four digits (line number) of the first peer reference’s fax number.

Enter the first peer reference’s email address, if available.

Enter the full name of the first practitioner who will provide call coverage for your patients when you are unavailable.

Enter the medical specialty of the first call coverage practitioner listed.

Enter the name of the facility for this previous affiliation. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address of the facility. Fill only if 'Does not apply' is 'No'.

Enter the month you started at this facility. Fill only if 'Does not apply' is 'No'.

Enter the day of the month you started at this facility. Fill only if 'Does not apply' is 'No'.

Enter the year you started at this facility. Fill only if 'Does not apply' is 'No'.

Enter the month you ended your affiliation with this facility. Fill only if 'Does not apply' is 'No'.

Enter the day of the month you ended your affiliation with this facility. Fill only if 'Does not apply' is 'No'.

Enter the year you ended your affiliation with this facility. Fill only if 'Does not apply' is 'No'.

Enter the name of your professional liability insurance carrier during this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the reason you left this facility or ended the affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name of the previous professional liability insurance carrier or provider. Fill only if 'Does not apply' is 'No'.

Enter the policy number for this previous professional liability insurance coverage. Fill only if 'Does not apply' is 'No'.

Check this box if the first listed previous professional liability policy was a claims-made policy. Fill only if 'Does not apply' is 'No'.

Check this box if the first listed previous professional liability policy was an occurrence policy. Fill only if 'Does not apply' is 'No'.

Enter the name of the local contact person for this insurance carrier. Fill only if 'Does not apply' is 'No'.

Enter the mailing address for the insurance carrier or local contact. Fill only if 'Does not apply' is 'No'.

Enter the area code of the contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the extension for the contact’s telephone number, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the area code of the contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the per-claim limit of liability for this policy. Fill only if 'Does not apply' is 'No'.

Enter the aggregate liability limit amount for this policy. Fill only if 'Does not apply' is 'No'.

Enter the contact’s email address, if available. Fill only if 'Does not apply' is 'No'.

Enter the month the policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the year the policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the month of the policy retroactive date, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the day of the month of the policy retroactive date, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the year of the policy retroactive date, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the month the policy expires. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the policy expires. Fill only if 'Does not apply' is 'No'.

Enter the year the policy expires. Fill only if 'Does not apply' is 'No'.

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

Enter the position or job title you held at this practice or employer.

Enter the name and job title of the contact person for this practice or employer.

Enter the area code for the practice/employer telephone number.

Enter the next three digits (prefix) of the practice/employer telephone number.

Enter the last four digits of the practice/employer telephone number.

Enter the telephone extension number, if applicable.

Enter the area code for the fax number.

Enter the next three digits (prefix) of the fax number.

Enter the last four digits of the fax number.

Enter the complete mailing address for this practice or employer.

Enter the month you started at this practice or employer.

Enter the year you started at this practice or employer.

Enter the month you ended this position at this practice or employer.

Enter the year you ended this position at this practice or employer.

Enter the contact person’s email address, if available.

Enter the name of your professional liability insurance carrier during this employment.

Enter the complete name of the residency institution and its street address. Fill only if 'Does not apply' is 'No'.

Enter the city where the residency institution is located. Fill only if 'Does not apply' is 'No'.

Enter the state where the residency institution is located. Fill only if 'Does not apply' is 'No'.

Enter the ZIP code for the residency institution’s address. Fill only if 'Does not apply' is 'No'.

Enter the email address for the residency program contact. Fill only if 'Does not apply' is 'No'.

Enter the residency specialty or program focus. Fill only if 'Does not apply' is 'No'.

Enter the area code of the residency program phone number. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits of the residency program phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the residency program phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code of the residency program fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits of the residency program fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the residency program fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the month you started this residency. Fill only if 'Does not apply' is 'No'.

Enter the year you started this residency. Fill only if 'Does not apply' is 'No'.

Enter the month you ended this residency. Fill only if 'Does not apply' is 'No'.

Enter the year you ended this residency. Fill only if 'Does not apply' is 'No'.

Enter the month the residency program was completed. Fill only if 'Does not apply' is 'No'.

Enter the year the residency program was completed. Fill only if 'Does not apply' is 'No'.

Check this box if you completed this residency program. Fill only if 'Does not apply' is 'No'.

Check this box if you did not complete this residency program. Fill only if 'Does not apply' is 'No'.

Enter the name/title of the fourth continuing medical education (CME) activity you completed. Fill only if 'Does not apply' is 'No'.

Enter the month in which you attended the fourth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year in which you attended the fourth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the total number of CME credit hours earned for the fourth CME activity. Fill only if 'Does not apply' is 'No'.

Check this box if you do have admitting privileges at the facility listed in the fourth current affiliation entry. Fill only if 'Does not apply' is 'No'.

Check this box if you do not have admitting privileges at the facility listed in the fourth current affiliation entry. Fill only if 'Does not apply' is 'No'.

Enter the name of the health care facility for this fourth current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code for the facility’s fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the facility’s fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the facility’s fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the facility’s complete mailing address (street, city, state, and ZIP code). Fill only if 'Does not apply' is 'No'.

Enter your status at this facility (e.g., active, courtesy, provisional, allied health). Fill only if 'Does not apply' is 'No'.

Enter the month of your appointment at this facility. Fill only if 'Does not apply' is 'No'.

Enter the day of your appointment at this facility. Fill only if 'Does not apply' is 'No'.

Enter the year of your appointment at this facility. Fill only if 'Does not apply' is 'No'.

Enter the email address for the facility contact. Fill only if 'Does not apply' is 'No'.

Enter the name of your professional liability (malpractice) insurance carrier for this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name/type of the fourth additional certification (e.g., ACLS, BLS, PALS).

Enter the license or certificate number/identifier for the fourth certification.

Enter the month the fourth certification was issued.

Enter the year the fourth certification was issued.

Enter the month the fourth certification expires.

Enter the year the fourth certification expires.

Enter the state or country that issued this health care license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the license, registration, or certificate identification number for this out-of-state credential. Fill only if 'Does not apply' is 'No'.

Enter the type of license, registration, or certificate (e.g., RN, PA, MD, etc.). Fill only if 'Does not apply' is 'No'.

Enter the year this license, registration, or certificate was originally obtained. Fill only if 'Does not apply' is 'No'.

Enter the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the day of the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year this license, registration, or certificate was relinquished, if applicable. Fill only if 'Does not apply' is 'No'.

Provide the reason for relinquishing, expiring, or otherwise ending this license, registration, or certificate, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the full name of the fourth practitioner who provides call coverage for your patients when you are unavailable.

Enter the medical specialty of the fourth practitioner who provides call coverage for your patients when you are unavailable.

Enter the name of the fourth previous professional liability insurance carrier or coverage provider. Fill only if 'Does not apply' is 'No'.

Enter the policy number for the fourth previous professional liability insurance policy. Fill only if 'Does not apply' is 'No'.

Check this box if the fourth previous professional liability policy is a claims-made policy. Fill only if 'Does not apply' is 'No'.

Check this box if the fourth previous professional liability policy is an occurrence policy. Fill only if 'Does not apply' is 'No'.

Enter the name of the local contact person for the fourth previous carrier/provider. Fill only if 'Does not apply' is 'No'.

Enter the mailing address for the fourth previous carrier/provider or its local contact. Fill only if 'Does not apply' is 'No'.

Enter the area code for the local contact’s telephone number for the fourth previous carrier/provider. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the local contact’s telephone number for the fourth previous carrier/provider. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the local contact’s telephone number for the fourth previous carrier/provider. Fill only if 'Does not apply' is 'No'.

Enter the telephone extension for the local contact, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the area code of the fax number for the fourth previous carrier/provider, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the fax number for the fourth previous carrier/provider, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the fax number for the fourth previous carrier/provider, if available. Fill only if 'Does not apply' is 'No'.

Enter the per-claim limit of liability for the fourth previous professional liability insurance policy. Fill only if 'Does not apply' is 'No'.

Enter the aggregate coverage amount for the fourth previous professional liability insurance policy. Fill only if 'Does not apply' is 'No'.

Enter the local contact’s email address for the fourth previous carrier/provider, if available. Fill only if 'Does not apply' is 'No'.

Enter the month the fourth previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the fourth previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the year the fourth previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the month of the retroactive date for the fourth previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the day of the month of the retroactive date for the fourth previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the year of the retroactive date for the fourth previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the month the fourth previous policy expired. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the fourth previous policy expired. Fill only if 'Does not apply' is 'No'.

Enter the year the fourth previous policy expired. Fill only if 'Does not apply' is 'No'.

Check this box if you have no gaps greater than two (2) months to explain.

Enter the activities performed and/or names of organizations/people that explain the gap in this time period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activities, employment, education, travel, or other explanation describing this gap period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activities performed and/or the organization or person names that explain the employment/training gap for this row. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activities performed and/or names of organizations/individuals that explain this employment/practice gap. Fill only if 'Does not apply' is 'No'.

Enter the starting month for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the starting year for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the ending month for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the ending year for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the activities performed and/or the names of employers, schools, or other organizations that explain this gap in Row 3. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began for Row 3. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began for Row 3. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended for Row 3. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended for Row 3. Fill only if 'Does not apply' is 'No'.

Enter the activities undertaken and/or names of organizations or individuals relevant to this gap period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period started. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period started. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activities, names, and/or explanation describing this employment/training gap for row 5. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap began for row 5. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap began for row 5. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap ended for row 5. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap ended for row 5. Fill only if 'Does not apply' is 'No'.

Enter the activity(ies) performed during this gap and/or the relevant organization or person name(s) for this period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activity, situation, or explanation describing what you were doing during this gap period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the activities performed and/or the names of organizations or individuals associated with this gap period. Fill only if 'Does not apply' is 'No'.

Enter the starting month for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the starting year for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the ending month for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the ending year for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the activities, employment, education, travel, or other explanation for this gap period. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period began. Fill only if 'Does not apply' is 'No'.

Enter the month when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the year when this gap period ended. Fill only if 'Does not apply' is 'No'.

Enter the graduate degree you received (e.g., MS, MA, MPH, PhD). Fill only if 'Does not apply' is 'No'.

Enter the month you started the graduate program. Fill only if 'Does not apply' is 'No'.

Enter the year you started the graduate program. Fill only if 'Does not apply' is 'No'.

Enter the month you graduated from the graduate program. Fill only if 'Does not apply' is 'No'.

Enter the year you graduated from the graduate program. Fill only if 'Does not apply' is 'No'.

Enter your graduate course of study or major. Fill only if 'Does not apply' is 'No'.

Check this box if you have no graduate education to report in this section.

Enter the graduate school name and its full street address. Fill only if 'Does not apply' is 'No'.

Enter the city where the graduate school is located. Fill only if 'Does not apply' is 'No'.

Enter the state where the graduate school is located. Fill only if 'Does not apply' is 'No'.

Enter your home street address (street number and name, and apartment/unit number if applicable).

Enter the city for your home address.

Enter the state for your home address.

Enter the ZIP code for your home address.

Enter the country for your home address.

Enter your immigrant visa number, if you have one.

Enter the date your visa expires.

Enter your current immigration/visa status.

Enter the type or category of visa you hold.

Enter the month of the incident. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the day of the month when the incident occurred. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the year when the incident occurred. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Provide a detailed narrative of the clinical details related to the incident. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the name and mailing address of the insurance carrier or professional liability provider that handled the claim. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the month when the internship began. Fill only if 'Does not apply' is 'No'.

Enter the year when the internship began. Fill only if 'Does not apply' is 'No'.

Enter the month when the internship ended. Fill only if 'Does not apply' is 'No'.

Enter the year when the internship ended. Fill only if 'Does not apply' is 'No'.

Enter the area code for the internship site's fax number. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix for the internship site's fax number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the internship site's fax number. Fill only if 'Does not apply' is 'No'.

Enter the city where the internship institution is located. Fill only if 'Does not apply' is 'No'.

Enter the state or province where the internship institution is located. Fill only if 'Does not apply' is 'No'.

Enter the ZIP or postal code for the internship institution's address. Fill only if 'Does not apply' is 'No'.

Enter the contact email address for the internship institution. Fill only if 'Does not apply' is 'No'.

Enter the full name of the internship institution and its complete street address. Fill only if 'Does not apply' is 'No'.

Enter the month in which the internship was completed. Fill only if 'Does not apply' is 'No'.

Enter the year in which the internship was completed. Fill only if 'Does not apply' is 'No'.

Enter the first three digits (area code) of the internship phone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits of the internship phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the internship phone number. Fill only if 'Does not apply' is 'No'.

Enter the type of internship and your specialty or focus area for this post-graduate year/internship. Fill only if 'Does not apply' is 'No'.

Enter your role in the legal action (e.g., primary defendant, co-defendant, or other). Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Describe the current status of the lawsuit, claim, or other legal action. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Check this box if you completed the medical/professional education program for this school.

Check this box if you did not complete the medical/professional education program for this school.

Enter the complete name of the medical/professional school and its street address for this education entry.

Enter the city where the medical/professional school is located.

Enter the state where the medical/professional school is located.

Enter the ZIP code for the medical/professional school address.

Enter the contact email address for the medical/professional school.

Enter the degree you received from this medical/professional school.

Enter the area code for the school phone number.

Enter the next three digits of the school phone number after the area code.

Enter the last four digits of the school phone number.

Enter the area code for the school fax number, if available.

Enter the next three digits of the school fax number after the area code, if available.

Enter the last four digits of the school fax number, if available.

Enter the month you started the program at this medical/professional school.

Enter the year you started the program at this medical/professional school.

Enter the month you ended attendance in the program at this medical/professional school.

Enter the year you ended attendance in the program at this medical/professional school.

Enter the month you completed the program at this medical/professional school.

Enter the year you completed the program at this medical/professional school.

Check this box if you completed the medical/professional education program for the second school listed.

Check this box if you did not complete the medical/professional education program for the second school listed.

Enter the full name of the medical/professional school and its street address for the second education entry.

Enter the city where the medical/professional school is located for the second education entry.

Enter the state where the medical/professional school is located for the second education entry.

Enter the ZIP code for the medical/professional school address for the second education entry.

Enter the contact email address for the medical/professional school for the second education entry.

Enter the degree you received from this medical/professional education program for the second entry.

Enter the first part of the school phone number for the second education entry.

Enter the second part of the school phone number for the second education entry.

Enter the third part of the school phone number for the second education entry.

Enter the first part of the school fax number (if available) for the second education entry.

Enter the second part of the school fax number (if available) for the second education entry.

Enter the third part of the school fax number (if available) for the second education entry.

Enter the month you started this medical/professional education program for the second entry.

Enter the year you started this medical/professional education program for the second entry.

Enter the month you ended attendance in this medical/professional education program for the second entry.

Enter the year you ended attendance in this medical/professional education program for the second entry.

Enter the month you completed this medical/professional education program for the second entry.

Enter the year you completed this medical/professional education program for the second entry.

Enter your Oregon license or registration number.

Enter the type of Oregon license or registration (e.g., professional license category).

Enter the month of the Oregon license or registration expiration date.

Enter the day of the Oregon license or registration expiration date.

Enter the year of the Oregon license or registration expiration date.

Check this box if you have been known by or have used any other name since starting professional training.

Check this box if you have not been known by or used any other name since starting professional training.

Enter any other name(s) you have used since starting professional training and the year(s) each name was used. Fill only if 'Yes' is 'Yes'.

Check this box if you participate in administration as part of your professional activities.

Check this box if you participate in teaching as part of your professional activities.

Check this box if you participate in research as part of your professional activities.

Check this box if you are retired from professional practice.

Check this box if you have other professional activities not listed and will provide an explanation.

Describe the other professional activity you engage in if it is not listed (e.g., administration, teaching, research, retired). Fill only if 'Other (explain)' is 'Yes'.

Check this box if you have never held any health care licenses, registrations, or certificates in any other state or country.

Enter the area code for your home telephone number.

Enter the next three digits (prefix) of your home telephone number.

Enter the last four digits of your home telephone number.

Enter the area code for your mobile or alternate telephone number.

Enter the next three digits (prefix) of your mobile or alternate telephone number.

Enter the last four digits of your mobile or alternate telephone number.

Enter the full legal name of the collaborating physician or collaborating physician group for the physician associate.

Check this box if you did not complete a Post-Graduate Year 1 (PGY-1) or internship and this section does not apply to you.

Check this box if you completed the Post-Graduate Year 1/Internship program. Fill only if 'Does not apply' is 'No'.

Check this box if you did not complete the Post-Graduate Year 1/Internship program. Fill only if 'Does not apply' is 'No'.

Enter the name of the practice or employer.

Enter your position or job title at this practice or employer.

Enter the area code for the telephone number.

Enter the next three digits of the telephone number.

Enter the last four digits of the telephone number.

Enter the telephone extension number, if applicable.

Enter the area code for the fax number.

Enter the next three digits of the fax number.

Enter the last four digits of the fax number.

Enter the month you started with this practice or employer.

Enter the year you started with this practice or employer.

Enter the month you ended with this practice or employer.

Enter the year you ended with this practice or employer.

Enter the name of the professional liability insurance carrier for this practice or employment.

Enter the practitioner's full legal last name, including any suffix (e.g., Jr., Sr., III) if applicable.

Enter the practitioner's full legal first name.

Enter the practitioner's full legal middle name.

Enter the practitioner's professional degree(s) (e.g., MD, DO, NP, PA-C) as they should appear on the application.

Enter the practitioner's full name as it should appear on this form. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Check this box if you have no previous affiliations to report in this section.

Check this box if you do not have any previous professional liability insurance carriers to list for the past five (5) years.

Enter the primary contact person's full name and their job title/position.

Enter the complete mailing address for the primary contact or practice/employer.

Enter the primary contact person's email address, if available.

Enter the primary credentialing contact’s full name and mailing address.

Enter the area code for the primary credentialing contact’s telephone number.

Enter the next three digits of the primary credentialing contact’s telephone number after the area code.

Enter the last four digits of the primary credentialing contact’s telephone number.

Enter the telephone extension for the primary credentialing contact, if applicable.

Enter the area code for the primary credentialing contact’s fax number.

Enter the next three digits of the primary credentialing contact’s fax number after the area code.

Enter the last four digits of the primary credentialing contact’s fax number.

Enter the primary credentialing contact’s email address.

Enter the full name of the primary office manager.

Enter the area code for the office manager’s telephone number.

Enter the next three digits of the office manager’s telephone number (prefix/exchange).

Enter the last four digits of the office manager’s telephone number (line number).

Enter the extension for the office manager’s telephone number, if applicable.

Enter the area code for the office manager’s fax number.

Enter the next three digits of the office manager’s fax number (prefix/exchange).

Enter the last four digits of the office manager’s fax number (line number).

Enter the area code for the exchange/answering service phone number.

Enter the three-digit prefix for the exchange/answering service phone number.

Enter the four-digit line number for the exchange/answering service phone number.

Enter the extension for the exchange/answering service phone number, if applicable.

Enter the area code for the pager number.

Enter the three-digit prefix for the pager number.

Enter the four-digit line number for the pager number.

Enter the office email address for the primary practice.

Enter the name of your primary practice, affiliation, or clinic.

Enter the department name for the primary practice if the practice is hospital-based.

Enter the Entity Type 2 (group) NPI number for the primary practice.

Enter the primary practice mailing/billing address (if different from the address listed above). Fill only if 'Primary Practice Street Address', 'Primary Practice City', 'Primary Practice County', 'Primary Practice State', 'Primary Practice ZIP Code' is different from Mailing/Billing Address (any).

Enter the name or department that the mailing/billing address should be directed to.

Enter the area code for the primary office telephone number.

Enter the three-digit prefix (central office code) for the primary office telephone number.

Enter the last four digits of the primary office telephone number.

Enter the extension for the primary office telephone number, if applicable.

Enter the area code for the primary office fax number.

Enter the three-digit prefix (central office code) for the primary office fax number.

Enter the last four digits of the primary office fax number.

Enter the area code for the patient appointment telephone number.

Enter the three-digit prefix (central office code) for the patient appointment telephone number.

Enter the last four digits of the patient appointment telephone number.

Enter the extension for the patient appointment telephone number, if applicable.

Enter the street address for the primary clinical practice location.

Enter the city where the primary clinical practice is located.

Enter the county where the primary clinical practice is located.

Enter the state where the primary clinical practice is located.

Enter the ZIP code for the primary clinical practice address.

Enter your primary clinical specialty (e.g., your provider taxonomy specialty) for directory listing purposes.

Check this box if you want to be designated as a primary care practitioner (PCP).

Check this box if you do not want to be designated as a primary care practitioner (PCP).

Enter the federal tax ID number or Social Security number used for business purposes.

Enter the name associated with the tax ID number provided above. Fill only if 'Federal Tax ID or SSN (Business Use)' is provided.

Enter the provider's individual (Entity Type 1) National Provider Identifier (NPI) number.

Enter the provider's Medicare identification number.

Enter the provider's Oregon Medicaid provider identification number.

Enter the race you identify as (optional).

Enter the ethnicity you identify as (optional).

Enter your primary language (optional).

List any current disabilities you have (optional).

Check this box if the claim was reported to any state or federal agency. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Check this box if the claim was not reported to any state or federal agency. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the name of the state or federal agency to which the claim was reported. Fill only if 'Yes' is 'Yes'.

Check this box if you do not have any residencies to report in this section.

Describe your role in the incident and the specific responsibilities and actions you performed. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the name of the health care facility for your second application currently in process. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility phone number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix of the facility phone number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility phone number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility fax number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix of the facility fax number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility fax number for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address of the facility for your second application in process. Fill only if 'Does not apply' is 'No'.

Enter your status with the facility for the second application in process (e.g., active, courtesy, provisional, allied health). Fill only if 'Does not apply' is 'No'.

Enter the month of submission for the second application in process. Fill only if 'Does not apply' is 'No'.

Enter the day of submission for the second application in process. Fill only if 'Does not apply' is 'No'.

Enter the year of submission for the second application in process. Fill only if 'Does not apply' is 'No'.

Enter the name of the board or organization that issued this certification. Fill only if 'Does not apply' is 'No'.

Enter the certification number assigned by the issuing board, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the specialty area for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the month you were certified or most recently recertified for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the year you were certified or most recently recertified for this board certification. Fill only if 'Does not apply' is 'No'.

Enter the month this board certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the year this board certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the city where the second clinical training program institution is located. Fill only if 'Does not apply' is 'No'.

Enter the state where the second clinical training program institution is located. Fill only if 'Does not apply' is 'No'.

Enter the ZIP code for the location of the second clinical training program institution. Fill only if 'Does not apply' is 'No'.

Enter the contact email address for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Check this box if you completed the second clinical training program. Fill only if 'Does not apply' is 'No'.

Check this box if you did not complete the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the month when you started the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the year when you started the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the month when you finished the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the year when you finished the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the month when you completed the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the year when you completed the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the full name of the institution and its street address for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the specialty/discipline for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the area code for the phone number for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the phone number for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the phone number for the second clinical training program. Fill only if 'Does not apply' is 'No'.

Enter the area code for the fax number for the second clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the fax number for the second clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the fax number for the second clinical training program, if available. Fill only if 'Does not apply' is 'No'.

Enter the name or title of the second continuing medical education (CME) activity you attended. Fill only if 'Does not apply' is 'No'.

Enter the month in which you attended the second CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year in which you attended the second CME activity. Fill only if 'Does not apply' is 'No'.

Enter the total number of CME credit hours earned for the second activity. Fill only if 'Does not apply' is 'No'.

Check this box if you have admitting privileges at this facility for the second current affiliation listed. Fill only if 'Does not apply' is 'No'.

Check this box if you do not have admitting privileges at this facility for the second current affiliation listed. Fill only if 'Does not apply' is 'No'.

Enter the name of the second current affiliated facility. Fill only if 'Does not apply' is 'No'.

Enter the area code for the second facility's phone number. Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the second facility's phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the second facility's phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code for the second facility's fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the middle three digits (prefix) of the second facility's fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the second facility's fax number (if available). Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address of the second current affiliated facility. Fill only if 'Does not apply' is 'No'.

Enter your status at the second facility (e.g., active, courtesy, provisional, allied health). Fill only if 'Does not apply' is 'No'.

Enter the month of your appointment at the second facility. Fill only if 'Does not apply' is 'No'.

Enter the day of your appointment at the second facility. Fill only if 'Does not apply' is 'No'.

Enter the year of your appointment at the second facility. Fill only if 'Does not apply' is 'No'.

Enter the contact email address for the second current affiliated facility. Fill only if 'Does not apply' is 'No'.

Enter the name of your professional liability insurance carrier for this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name/type of the second other certification (e.g., ACLS, BLS, PALS).

Enter the certificate or license number for the second other certification.

Enter the month the second other certification was issued.

Enter the year the second other certification was issued.

Enter the month the second other certification expires.

Enter the year the second other certification expires.

Enter the state or country that issued this other health care license, registration, or certificate (second entry). Fill only if 'Does not apply' is 'No'.

Enter the license, registration, or certificate identification number for this second other state/country credential. Fill only if 'Does not apply' is 'No'.

Enter the type of credential held (e.g., professional license, registration, or certificate) for this second other state/country entry. Fill only if 'Does not apply' is 'No'.

Enter the year you originally obtained this second other state/country license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the month this second other state/country license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the day of the month this second other state/country license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year this second other state/country license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year you relinquished this second other state/country license, registration, or certificate, if applicable. Fill only if 'Does not apply' is 'No'.

Provide the reason related to this second other state/country license, registration, or certificate (e.g., lapse, surrender, discipline, or other explanation). Fill only if 'Does not apply' is 'No'.

Enter the full name of your second peer reference.

Enter the medical specialty of your second peer reference.

Enter the complete address and location name for your second peer reference, including department if applicable.

Enter the professional credentials of your second peer reference (e.g., MD, DO, RN).

Describe your professional relationship to this peer reference (e.g., colleague, supervisor, collaborator).

Enter the area code for the second peer reference’s telephone number.

Enter the next three digits of the second peer reference’s telephone number.

Enter the last four digits of the second peer reference’s telephone number.

Enter the telephone extension for the second peer reference, if applicable.

Enter the area code for the second peer reference’s fax number.

Enter the next three digits of the second peer reference’s fax number.

Enter the last four digits of the second peer reference’s fax number.

Enter the email address for the second peer reference, if available.

Enter the full name of the second practitioner who will provide call coverage for your patients when you are unavailable.

Enter the medical specialty of the second practitioner listed for call coverage.

Enter the name of the facility for this previous affiliation. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility phone number. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix (central office code) of the facility phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility fax number. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix (central office code) of the facility fax number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility fax number. Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address for the facility (street, city, state/province, and postal code). Fill only if 'Does not apply' is 'No'.

Enter the month you started this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the day of the month you started this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the year you started this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the month you ended this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the day of the month you ended this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the year you ended this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name of the professional liability insurance carrier for this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the reason you left this facility or affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name of the second previous professional liability insurance carrier/provider. Fill only if 'Does not apply' is 'No'.

Enter the policy number for the second previous professional liability insurance coverage. Fill only if 'Does not apply' is 'No'.

Check this box if the second previous professional liability policy’s type of coverage was claims-made. Fill only if 'Does not apply' is 'No'.

Check this box if the second previous professional liability policy’s type of coverage was occurrence-based. Fill only if 'Does not apply' is 'No'.

Enter the name of the local contact for the second previous professional liability insurance carrier. Fill only if 'Does not apply' is 'No'.

Enter the mailing address for the second previous professional liability insurance carrier/contact. Fill only if 'Does not apply' is 'No'.

Enter the area code for the second previous carrier contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the second previous carrier contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the second previous carrier contact’s telephone number. Fill only if 'Does not apply' is 'No'.

Enter the extension number for the second previous carrier contact’s telephone number, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the area code for the second previous carrier contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the second previous carrier contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits (line number) of the second previous carrier contact’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the per-claim limit of liability for the second previous professional liability policy. Fill only if 'Does not apply' is 'No'.

Enter the aggregate coverage amount for the second previous professional liability policy. Fill only if 'Does not apply' is 'No'.

Enter the email address for the second previous carrier contact, if available. Fill only if 'Does not apply' is 'No'.

Enter the month the second previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the second previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the year the second previous policy became effective. Fill only if 'Does not apply' is 'No'.

Enter the month of the retroactive date for the second previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the day of the month of the retroactive date for the second previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the year of the retroactive date for the second previous policy, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the month the second previous policy expired. Fill only if 'Does not apply' is 'No'.

Enter the day of the month the second previous policy expired. Fill only if 'Does not apply' is 'No'.

Enter the year the second previous policy expired. Fill only if 'Does not apply' is 'No'.

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

Enter the position or job title you held at this practice or employer.

Enter the name and job title of a contact person at this practice or employer who can verify your employment.

Enter the area code of the telephone number for this practice or employer.

Enter the next three digits (prefix) of the telephone number for this practice or employer.

Enter the last four digits (line number) of the telephone number for this practice or employer.

Enter the phone extension number, if applicable.

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

Enter the next three digits (prefix) of the fax number for this practice or employer.

Enter the last four digits (line number) of the fax number for this practice or employer.

Enter the complete mailing address of the practice or employer.

Enter the month you started working at this practice or employer.

Enter the year you started working at this practice or employer.

Enter the month you ended working at this practice or employer.

Enter the year you ended working at this practice or employer.

Enter the email address for the contact person at this practice or employer, if available.

Enter the name of your professional liability insurance carrier associated with this position.

Enter the full name of the residency institution and its street address. Fill only if 'Does not apply' is 'No'.

Enter the city where the residency institution is located. Fill only if 'Does not apply' is 'No'.

Enter the state where the residency institution is located. Fill only if 'Does not apply' is 'No'.

Enter the ZIP code for the residency institution's address. Fill only if 'Does not apply' is 'No'.

Enter the contact email address for the residency program or institution. Fill only if 'Does not apply' is 'No'.

Enter the specialty area of this residency. Fill only if 'Does not apply' is 'No'.

Enter the area code for the residency contact phone number. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the residency contact phone number. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the residency contact phone number. Fill only if 'Does not apply' is 'No'.

Enter the area code for the residency fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the next three digits (prefix) of the residency fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the residency fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the month you started this residency. Fill only if 'Does not apply' is 'No'.

Enter the year you started this residency. Fill only if 'Does not apply' is 'No'.

Enter the month you ended this residency. Fill only if 'Does not apply' is 'No'.

Enter the year you ended this residency. Fill only if 'Does not apply' is 'No'.

Enter the month you completed the residency program. Fill only if 'Does not apply' is 'No'.

Enter the year you completed the residency program. Fill only if 'Does not apply' is 'No'.

Check this box if you completed the second residency program listed in this section. Fill only if 'Does not apply' is 'No'.

Check this box if you did not complete the second residency program listed in this section. Fill only if 'Does not apply' is 'No'.

Enter the full mailing address for the secondary credentialing contact.

Enter the area code for the secondary credentialing contact’s telephone number.

Enter the next three digits (prefix) of the secondary credentialing contact’s telephone number.

Enter the last four digits (line number) of the secondary credentialing contact’s telephone number.

Enter the telephone extension for the secondary credentialing contact, if applicable.

Enter the area code for the secondary credentialing contact’s fax number.

Enter the next three digits (prefix) of the secondary credentialing contact’s fax number.

Enter the last four digits (line number) of the secondary credentialing contact’s fax number.

Enter the email address for the secondary credentialing contact.

Enter the full name of the office manager for the secondary practice location.

Enter the area code for the secondary office manager’s telephone number.

Enter the next three digits (prefix) of the secondary office manager’s telephone number.

Enter the last four digits (line number) of the secondary office manager’s telephone number.

Enter the extension for the secondary office manager’s telephone number, if applicable.

Enter the area code for the secondary office manager’s fax number.

Enter the next three digits (prefix) of the secondary office manager’s fax number.

Enter the last four digits (line number) of the secondary office manager’s fax number.

Enter the area code for the secondary practice’s exchange/answering service telephone number.

Enter the prefix (middle three digits) for the secondary practice’s exchange/answering service telephone number.

Enter the last four digits for the secondary practice’s exchange/answering service telephone number.

Enter the extension for the secondary practice’s exchange/answering service telephone number, if applicable.

Enter the area code for the secondary practice pager number.

Enter the prefix (middle three digits) for the secondary practice pager number.

Enter the last four digits for the secondary practice pager number.

Enter the email address for the secondary practice office.

Enter the name of your secondary practice, affiliation, or clinic.

Enter the department name for the secondary practice if it is hospital-based.

Enter the Entity Type 2 (group) NPI number for the secondary practice.

Enter the mailing or billing street address for the secondary practice, if different from the address listed above. Fill only if 'Secondary Practice Street Address', 'Secondary Practice City', 'Secondary Practice County', 'Secondary Practice State', 'Secondary Practice ZIP Code' is different from Mailing/Billing Address (any).

Enter the attention line (person or department) for the secondary practice mailing/billing address.

Enter the area code for the secondary practice primary office telephone number.

Enter the three-digit prefix for the secondary practice primary office telephone number.

Enter the four-digit line number for the secondary practice primary office telephone number.

Enter the extension for the secondary practice primary office telephone number, if applicable.

Enter the area code for the secondary practice primary office fax number.

Enter the three-digit prefix for the secondary practice primary office fax number.

Enter the four-digit line number for the secondary practice primary office fax number.

Enter the area code for the secondary practice patient appointment telephone number.

Enter the three-digit prefix for the secondary practice patient appointment telephone number.

Enter the four-digit line number for the secondary practice patient appointment telephone number.

Enter the extension for the secondary practice patient appointment telephone number, if applicable.

Enter the street address for the secondary clinical practice location.

Enter the city for the secondary clinical practice address.

Enter the county for the secondary clinical practice address.

Enter the state for the secondary clinical practice address.

Enter the ZIP code for the secondary clinical practice address.

Enter the federal tax ID number or Social Security number used for business purposes for the secondary practice/affiliation.

Enter the name of the individual or entity associated with the tax ID number listed above for the secondary practice/affiliation. Fill only if 'Secondary Practice Federal Tax ID or SSN' is provided.

Enter the month when the settlement, judgment, or dismissal occurred. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the day of the month when the settlement, judgment, or dismissal occurred. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the year when the settlement, judgment, or dismissal occurred. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the dollar amount of the settlement or judgment that was attributed to you. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the date on which the practitioner signs the attestation statement.

Enter the name or title of the sixth CME activity you completed. Fill only if 'Does not apply' is 'No'.

Enter the month you attended the sixth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year you attended the sixth CME activity. Fill only if 'Does not apply' is 'No'.

Enter the number of CME credit hours earned for the sixth CME activity. Fill only if 'Does not apply' is 'No'.

Describe any subsequent events after the incident, including the patient’s clinical outcome. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the month when the suit or claim was filed. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the day of the month when the suit or claim was filed. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the year when the suit or claim was filed. Fill only if 'Have any professional liability claims or lawsuits ever been closed and/or filed against you?' is 'Yes'.

Enter the area code for the telephone number.

Enter the three-digit prefix (central office code) for the telephone number.

Enter the last four digits of the telephone number.

Enter the telephone extension number, if applicable.

Enter the name of the board that issued this certification. Fill only if 'Does not apply' is 'No'.

Enter the certification number assigned by the issuing board, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the specialty area covered by this board certification. Fill only if 'Does not apply' is 'No'.

Enter the month you were certified or recertified for this specialty. Fill only if 'Does not apply' is 'No'.

Enter the year you were certified or recertified for this specialty. Fill only if 'Does not apply' is 'No'.

Enter the month this certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the year this certification expires, if any. Fill only if 'Does not apply' is 'No'.

Enter the name or title of the third continuing medical education (CME) activity you completed. Fill only if 'Does not apply' is 'No'.

Enter the month you attended the third CME activity. Fill only if 'Does not apply' is 'No'.

Enter the year you attended the third CME activity. Fill only if 'Does not apply' is 'No'.

Enter the number of CME credit hours earned for the third CME activity. Fill only if 'Does not apply' is 'No'.

Check this box if you have admitting privileges at the third listed current affiliation facility. Fill only if 'Does not apply' is 'No'.

Check this box if you do not have admitting privileges at the third listed current affiliation facility. Fill only if 'Does not apply' is 'No'.

Enter the name of the health care facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility phone number for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix of the facility phone number for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility phone number for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the area code of the facility fax number for your third current affiliation, if available. Fill only if 'Does not apply' is 'No'.

Enter the three-digit prefix of the facility fax number for your third current affiliation, if available. Fill only if 'Does not apply' is 'No'.

Enter the last four digits of the facility fax number for your third current affiliation, if available. Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address of the facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter your status at this facility (e.g., active, courtesy, provisional, allied health, etc.) for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the month of your appointment at this facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the day of your appointment at this facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the year of your appointment at this facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the contact email address associated with this facility for your third current affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name of your professional liability insurance carrier for this facility affiliation. Fill only if 'Does not apply' is 'No'.

Enter the name/type of the third other certification (e.g., ACLS, BLS, ATLS).

Enter the certificate or license number associated with the third other certification.

Enter the month the third other certification was issued or obtained.

Enter the year the third other certification was issued or obtained.

Enter the month the third other certification expires.

Enter the year the third other certification expires.

Enter the state or country that issued this other license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the license, registration, or certificate number issued by the state or country. Fill only if 'Does not apply' is 'No'.

Enter the type of license, registration, or certificate (for example, professional license, registration, or certification). Fill only if 'Does not apply' is 'No'.

Enter the year you first obtained this license, registration, or certificate. Fill only if 'Does not apply' is 'No'.

Enter the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the day of the month this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year this license, registration, or certificate expires. Fill only if 'Does not apply' is 'No'.

Enter the year you relinquished this license, registration, or certificate, if applicable. Fill only if 'Does not apply' is 'No'.

Provide the reason for relinquishing or allowing this license, registration, or certificate to expire, if applicable. Fill only if 'Does not apply' is 'No'.

Enter the full name of the third peer reference.

Enter the medical specialty or professional specialty of the third peer reference.

Enter the full name of the third practitioner who provides call coverage for your patients when you are unavailable.

Enter the medical specialty of the third practitioner who provides call coverage for your patients when you are unavailable.

Enter the name of the third previous affiliated facility. Fill only if 'Does not apply' is 'No'.

Enter the first part of the third previous facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the second part of the third previous facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the final part of the third previous facility’s phone number. Fill only if 'Does not apply' is 'No'.

Enter the first part of the third previous facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the second part of the third previous facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the final part of the third previous facility’s fax number, if available. Fill only if 'Does not apply' is 'No'.

Enter the complete mailing address of the third previous affiliated facility. Fill only if 'Does not apply' is 'No'.

Enter the month you started this affiliation. Fill only if 'Does not apply' is 'No'.

Enter the day of the month you started this affiliation. Fill only if 'Does not apply' is 'No'.