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The Minnesota Uniform Credentialing Application plays a crucial role for Physicians, Dentists, and Allied Health Professionals in the state, streamlining the reappointment process to maintain their professional standing. Designed to gather comprehensive and accurate information, this detailed form requires applicants to provide personal data, credentialing contact information, and specifics about their current and additional practice locations. It emphasizes the importance of legibility, whether filled out by hand or electronically, to avoid any misunderstandings. Applicants must include complete street addresses, phone, fax, and e-mail details for various categories like education/training, past employment, hospital affiliations, and references. Moreover, it mandates the disclosure of any potential gaps in the applicant's professional history, ensuring a continuous and verifiable career timeline. Completing this form accurately is imperative as it contributes to the evaluation of the professional's qualifications and their ability to provide quality healthcare services. The application also addresses the practitioner's fluency in languages other than English, indicating the inclusive approach towards patient care. Emphasizing the need for detailed responses, the form allows additional sheets for extensive information, underlining the exhaustive nature of the credentialing process in Minnesota.

Minnesota Uniform Credentialing Application Example

Minnesota Uniform Credentialing Application

Reappointment

Physician/Dentist/Allied Health Professional

Applicant Name (as shown on your state license):

___________________________________________________________________________________________________________

LastFirstMiddleSuffixTitle

CREDENTIALING CONTACT INFORMATION

 

Name

_________________________________________________________

Phone Number _______________________________

Address

_________________________________________________________

Fax Number _______________________________

 

_________________________________________________________

E-mail ______________________________________

 

_________________________________________________________

 

 

 

 

This Box to be Completed by Allied Health Professionals Only

Profession/Title _______________________________________________________

Sponsoring/Collaborative Physician _______________________________________

(Must complete if PA-C or APRN)

Instructions

The reappointment application and attachments should be filled out completely and accurately and must be legible or electronically generated. If more space is needed than provided on the application, please attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. ALL SIGNATURES AND DATES MUST BE CLEARLY LEGIBLE.

Please verify that you have:

Provided complete street address, phone, fax and e-mail addresses wherever indicated, including education/training, past employment, hospital affiliations & references

Designate dates by month, day and year time frames

Answered all of the Disclosure Questions on Pages 11 and 12 and enclosed explanations for affirmative answers

Signed and dated the Attestation Signature and Date statement (Page 13)

Signed and dated the Authorization and Release (Page 14)

All Information Must Be Printed in Black Ink or Electronically Generated

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Practitioner Name:

Last:

First:

Middle:

Practitioner NPI:

Practitioner Race and Ethnicity Information

Race and/or ethnicity (for health plan use only): (The following information is optional and may be used in provider directories to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members.)

Select one or more

 

 

American Indian or Alaska Native

 

Native Hawaiian or Other Pacific Islander

 

Hispanic or Latino

 

 

 

 

categories:

 

Asian

 

White

 

Prefer not to say

 

 

 

Black or African American

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if you do not wish for your race and/or ethnicity to be displayed in provider directories:

If provided on the credentialing application, the health plan may utilize race and/or ethnicity information in provider directories or in internal resources to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members. Providing race and/or ethnicity information on the credentialing application is entirely optional and refusal to provide this information will NOT subject you to adverse treatment. This information will not be considered in making any decisions regarding your credentialing.

Personal Data

Name (as shown on your state license):

__________________________________________________________________________________________________________________

Last

First

 

Middle

Suffix

Title

All Former Aliases: _____________________________________ Spouse Name (optional): _____________________________

Date of Birth: ___________________________________

Gender:

Male

Female

 

Social Security Number: ___________________________________ NPl: _________________________________________

Current Home Address:

 

 

 

 

 

______________________________________________________________________________________________

 

Street

 

 

City/State/Country

Zip Code

 

Preferred Mailing Address: Office

Home

Practitioner’s Preferred E-mail address: ___________________________________

Cell Phone Number: ___________________________________ Home Phone Number: ___________________________________________

Do you speak a language other than English with sufficient fluency to treat patients who speak only that language? Yes No

If yes, specify languages: _____________________________________________________________________________________________

Primary or Pending Practice Location

Primary Practice Location/Clinic Name: __________________________________________________________________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Office Phone Number: ______________________________________ Fax Number: ______________________________________________

Federal Tax ID Number: ______________________________________ Type II NPI: _____________________________________________

E-mail Address: ____________________________________________________________________________________________________

Start Date (at this location): ___________________________________________________________

Practicing as: Primary Care

Specialist

Urgent Care

Locum Tenens

Moonlighting Resident

Hospitalist

Hospital Based only

Teaching/Research only

Other (specify) _______________________________________

Accepting new patients? Yes

No

Directory Suppress?

Yes

No

 

 

Primary Specialty in which care will be provided: __________________________________________________________________________

Sub Specialty (ies) in which care will be provided: _________________________________________________________________________

Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet):

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 2 of 17

Additional Practice Location(s) – Since Last Reappointment Applicant Name:

Other Practice Name: ____________________________________________________ Phone Number: _____________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

E-mail Address: __________________________________________ Fax Number: _______________________________________________

Federal Tax ID Number (if different from primary): _____________________________ Type II NPI: __________________________________

Credentialing Contact: ________________________________________________________ Phone Number: __________________________

Start Date (at this location): ___________________________________________________________

Practicing as: Primary Care

Specialist

Urgent Care

Locum Tenens

Moonlighting Resident

Hospitalist

Hospital Based only

Teaching/Research only

Other (specify) ________________________________________

Accepting new patients? Yes

No

Directory Suppress?

Yes

No

 

 

Primary Specialty in which care will be provided: ___________________________________________________________________________

Sub Specialty (ies) in which care will be provided: __________________________________________________________________________

Fellowship/Post-Graduate/Professional Training – Since your last reappointment

(Month, day and year required)

 

 

 

From: _______________

Institution Name: _____________________________________________________________________________

To:

_______________

Type of Program/Specialty: ____________________________________________________________________

 

 

Completed Training: Yes No If no, expected completion date: ___________________________________

 

 

If not successfully completed, explain: ____________________________________________________________

 

 

Program Director: ____________________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ___________________________________ Fax Number: _______________________________

 

 

E-mail address: _____________________________________________________________________________

Professional and Academic/Faculty Affiliations - Since your last reappointment

 

 

 

 

 

 

(Month, day and year required)

 

 

 

From: ______________

Institution Name: _____________________________________________________________________________

To:

_______________

Appointment Held/Position: _____________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

Phone Number: _____________________________________ Fax Number: _____________________________

E-mail address: _____________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 3 of 17

Chronological Employment/Practice History (include Military Service)

Applicant Name:

 

 

(Additional space is provided on the Chronological Employment/Practice History Addendum. You may make extra copies of page 16 for additional employments.)

Chronological listing [month/day/year] of employment/practice history since your last reappointment. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOCLOGY.

(Month, day and year required)

From: _______________

Organization Name: __________________________________________________________________________

To: _______________

Title/Position: _______________________________________________________________________________

 

Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open? Yes No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

 

Street

City/State/Country

Zip Code

 

Phone Number: ______________________________________ Fax Number: ____________________________

 

E-mail address: ______________________________________________________________________________

From: _______________

Organization Name: __________________________________________________________________________

To: _______________

Title/Position: _______________________________________________________________________________

 

Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open? Yes No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

 

Street

City/State/Country

Zip Code

 

Phone Number: ______________________________________ Fax Number: ____________________________

 

E-mail address: _____________________________________________________________________________

From: _______________

Organization Name: __________________________________________________________________________

To: _______________

Title/Position: _______________________________________________________________________________

 

Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open? Yes No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ______________________________________ Fax Number: ____________________________

E-mail address: _____________________________________________________________________________

Check here if you have additional employment history on attached Chronological Employment/Practice History Addendum (page 16)

Time Gaps: Explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice - since your last reappointment (if additional space is required, you may make extra copies of page 16 for additional time gaps.)

(Month, day and year required)

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

From: _______________

Explain: ____________________________________________________________________________________

To:

_______________

___________________________________________________________________________________________

Check here if you have additional time gap information on attached Chronological Employment/Practice History Addendum (page 16)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 4 of 17

Primary Hospital Affiliation

Applicant Name:

 

 

(pertinent to Primary or Pending Practice Location listed on page 2)

If no hospital admitting privileges, describe method/coverage for continuity of care. Please provide covering physician’s name, if applicable.

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

(Month, day and year required)

 

 

 

From: _______________

Facility Name: _______________________________________________________________________________

To:

_______________

Type/category of privilege/affiliation (active, courtesy, etc.): ___________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

Admitting Privileges:

Yes No (If no, please complete box above)

 

 

 

Other Hospital Affiliations - Since your last reappointment (Additional space is provided on the Hospital Affiliation

Addendum. You may make extra copies of page 17 for additional affiliations.)

 

 

 

(Month, day and year required)

 

 

 

From: _______________

Facility Name: _________________________________________________________________________

To:

______________

Former Facility Name (if applicable): ____________________________________________

 

Facility Still Open?

 

Yes No

 

 

 

 

 

 

Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

Admitting Privileges:

Yes No (If no, please complete box above)

 

 

 

From: _______________

Facility Name: _________________________________________________________________________

To:

______________

Former Facility Name (if applicable): ____________________________________________

 

Facility Still Open?

 

Yes No

 

 

 

 

 

 

Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________

Application Pending

Department Chairperson: ______________________________________________________________________

 

 

Address: ___________________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: _____________________________________ Fax Number: _____________________________

 

 

E-mail address: ______________________________________________________________________________

Admitting Privileges:

Yes No (If no, please complete box above)

 

 

 

Check here if you have additional hospital affiliations on attached Hospital Affiliation Addendum (page 17)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 5 of 17

Specialty/Subspecialty Certification

Applicant Name:

 

 

(Additional space is provided on the Specialty and Licensure Addendum, page 17. You may make extra copies of page 17 or attach a separate sheet for additional Specialty and Licensure.)

Primary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Secondary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending

Check here if you have additional specialty on attached Specialty and Licensure Addendum (page 18)

If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Licensure - List all past, current and pending professional licenses.

(Additional space is provided on the Specialty and Licensure Addendum, page 18. You may make extra copies of page 18 or attach a separate sheet for additional Specialty and Licensure.)

License Type

State

License Number

Date Issued

Expiration Date

License Status

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

__________

________

_________________

_______________

_______________

Active Inactive Pending

Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 18)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 6 of 17

Drug Enforcement Administration Registration

Applicant Name:

NOTE: Address on DEA certificate must be in state where you will be practicing as applicable to this application.

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules? Yes No, please explain _________________________________________________________

If you do not maintain a DEA certificate, please explain:

Not applicable to practice DEA certificate pending; date application submitted to DEA: ___________________________________

Other ______________________________________________________________________________________________________

State Controlled Substance Certification/Registration (If applicable - not applicable to MN, WI, ND).

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Life Support Certification

Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)?

Yes No

If Yes: Type of Certification

Expiration Date(s)

___________________________________________________________

_______________

___________________________________________________________

_______________

___________________________________________________________

_______________

___________________________________________________________

_______________

Continuing Education Attestation

Please read the following attestation carefully before signing and dating the statement.

I hereby certify that I have a sufficient number of CE credits to meet the licensure requirements and attest that an appropriate percentage relate to my specialty. I understand that these credits may be audited by an individual facility based on their individual requirements.

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Signature: __________________________________________________________ Date: _________________________

Name: ______________________________________________________________________________________________

(please print or type)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 7 of 17

Liability Insurance

Applicant Name:

Insurance Carrier for Primary and Pending Practice Location (You may attach a separate sheet for additional Liability Insurance.)

Enclose a copy of professional liability insurance coverage (e.g., face sheet/verification of self-insurance) for primary practice location to include effective dates, insurance carrier, expiration date, coverage limits, and name of each provider covered. If additional space is required, attach a separate sheet.

Coverage dates:

(Month, day and year required)

 

 

 

Start:

_______________

Current Insurance Carrier Name: ___________________________________________________________

Expire:

_______________

Address: _______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ________________________________ Fax Number: ______________________________

 

 

E-mail address: _________________________________________________________________________

Certificate Pending

Name in which policy issued: ______________________________________________________________

 

 

Policy number: _________________________________________________________________________

 

 

Amount of coverage (per occurrence): _______________________________________________________

 

 

Amount of coverage (per aggregate): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

 

 

Phone Number: ________________________________ Fax Number: _____________________________

 

 

E-mail address: _________________________________________________________________________

 

 

Name in which policy issued: ______________________________________________________________

 

 

Policy number: _________________________________________________________________________

 

 

Amount of coverage (per occurrence): _______________________________________________________

 

 

Amount of coverage (per aggregate): ________________________________________________________

Start:

_______________

Insurance Carrier Name: _________________________________________________________________

Expire:

_______________

Address: ______________________________________________________________________________

 

 

Street

City/State/Country

Zip Code

Phone Number: ________________________________ Fax Number: _____________________________

E-mail address: _________________________________________________________________________

Name in which policy issued: ______________________________________________________________

Policy number: _________________________________________________________________________

Amount of coverage (per occurrence): _______________________________________________________

Amount of coverage (per aggregate): ________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 8 of 17

Professional/Peer References

Applicant Name:

 

 

List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation of your work. A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) Limit to one (1) current office associate. Do not include your residency director, fellowship director, relatives, or pending partners. At least one reference should be in your specialty (and if possible from the same subspecialty). Provide current and complete addresses. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you.

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Immune Status Information for Reappointment – Please provide immunity status by completing the question below.

DATE OF LAST PPD/MANTOUX:

Results:

Signature:

 

Date:

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 9 of 17
↓ Minnesota Uniform Credentialing Application File

Form Characteristics

Fact Name Description
Application Type The form is used for the reappointment of physicians, dentists, and allied health professionals.
Information Required Applicants must provide their name as it appears on their state license, along with credentialing contact information, personal data, employment/practice history, and details about additional practice locations.
Supporting Physician Details Allied health professionals must supply the name of a sponsoring or collaborative physician if applicable.
Completion Instructions The application should be completed fully and legibly, without abbreviations. All signatures and dates must be clearly legible.
Information Confirmation Applicants must verify addresses and contact information, answer disclosure questions, and provide signatures on designated sections of the form.
Language Proficiency Applicants are asked to identify if they speak any languages other than English with enough fluency to treat patients who only speak that language.
Practice Location Details Details about the primary or pending practice location, including the clinic name, address, and the medical services offered, are required.
Professional Training Details about fellowship, post-graduate, or professional training since the last reappointment must be included.
Chronological Employment/Practice History A comprehensive employment and practice history since the last reappointment is necessary, with no gaps in chronology.

Steps to Writing Minnesota Uniform Credentialing Application

Filling out the Minnesota Uniform Credentialing Application form is a straightforward process that requires attention to detail. It's essential that the information provided is accurate and complete to ensure a smooth credentialing process. The form is designed for reappointment and is applicable to physicians, dentists, and allied health professionals. Below are the steps you should follow to fill out the form correctly.

  1. Start by entering your Applicant Name as shown on your state license, including the last, first, middle name, suffix, and title.
  2. Fill in the Credentialing Contact Information section with the name, phone number, address, fax number, and email address of the person to be contacted regarding your credentialing.
  3. For Allied Health Professionals Only, specify your profession/title and the sponsoring/collaborative physician's name.
  4. Review the instructions carefully to ensure you understand the requirements, including the need for legibility, no abbreviations, and clear signatures and dates.
  5. Ensure you have provided complete information for street address, phone, fax, and email addresses wherever indicated throughout the form.
  6. Fill in the Personal Data section with details such as all former aliases, spouse name (optional), date of birth, gender, Social Security Number, NPI, and current home address. Also, indicate whether you prefer your office or home as your mailing address and provide your preferred email address and phone numbers.
  7. Indicate if you speak a language other than English fluently enough to treat patients who speak only that language, and specify the languages.
  8. Provide information about your Primary or Pending Practice Location, including the clinic name, address, phone number, fax number, Federal Tax ID Number, Type II NPI, and email address. Also, indicate your start date, type of practice, and specialties. Include if you are accepting new patients and if you want your directory suppressed.
  9. List Additional Practice Location(s) since your last reappointment, with the same level of detail as your primary practice location.
  10. Detail your Fellowship/Post-Graduate/Professional Training since your last reappointment, including institution name, type of program/specialty, dates, and program director.
  11. Update your Professional and Academic/Faculty Affiliations since your last reappointment, including institution name, position, and dates.
  12. Provide a detailed Chronological Employment/Practice History, including reasons for leaving and contact information for employment verification. Explicitly explain any gaps in your practice history of greater than three months.
  13. For your Primary Hospital Affiliation, include facility name, type of privilege/affiliation, and department chairperson. Explain your method for continuity of care if you have no admitting privileges.
  14. Document any Other Hospital Affiliations using the same format as the section for your primary hospital affiliation.
  15. Answer all the Disclosure Questions on pages 10 and 11, providing explanations for any affirmative answers.
  16. Ensure you sign and date the Attestation Signature and Date statement on page 12, and the Authorization and Release on page 13.

Upon completion, double-check the application to ensure all information is accurate and that no sections have been missed. Remember, all information must be printed in black ink or electronically generated. The completeness and accuracy of this application are paramount for a successful credentialing process.

Listed Questions and Answers

  1. What is the purpose of the Minnesota Uniform Credentialing Application?

    The Minnesota Uniform Credentialing Application is designed for physicians, dentists, and allied health professionals applying for reappointment. It is a comprehensive way to provide necessary information about personal data, practice locations, employment history, and more to healthcare organizations and insurance providers for the purposes of credentialing.

  2. Who needs to complete the Minnesota Uniform Credentialing Application?

    Physicians, dentists, and allied health professionals seeking reappointment within the state of Minnesota must complete this application. Specifically, if you are a Physician Assistant-Certified (PA-C) or an Advanced Practice Registered Nurse (APRN), you must also provide information about your sponsoring or collaborative physician.

  3. What information is required on the application?

    The application requires a variety of information including personal data, the name and contact information of credentialing contacts, details about primary and any additional practice locations, a chronological employment/practice history, gaps in employment, primary and other hospital affiliations, and education and training credentials since your last reappointment. Complete, legible responses and all necessary signatures and dates are crucial for the application to be processed.

  4. Can I submit the application electronically?

    Yes, the application can be filled out legibly or electronically generated. All provided information must be printed in black ink if filled out by hand. It is essential that electronic submissions are clear and easily readable to ensure that there are no delays in the credentialing process.

  5. What if I need more space than what the form provides?

    If you find the space provided on the application is insufficient, you are encouraged to attach additional sheets as necessary. Be sure to reference the specific question being answered on these additional sheets to ensure clarity and completeness of your application.

  6. How should I handle employment gaps or time gaps in my application?

    Any gaps or interruptions in medical practice or professional practice lasting more than three months since your last reappointment must be clearly explained. If additional space is required beyond what the application provides, you may use the Chronological Employment/Practice History Addendum or attach extra sheets, detailing these gaps with precise dates and explanations.

  7. Are abbreviations allowed on the application?

    No, the application specifically requests that no abbreviations be used. This helps to ensure clarity and prevent misunderstandings or delays in the processing of your application.

  8. What is the significance of signing the Attestation Signature and Date statement and the Authorization and Release?

    Signing these sections is legally binding and confirms that the information you have provided is accurate and true to the best of your knowledge. It also authorizes the release of this information for the purposes of credentialing. It is crucial that these sections are signed and dated clearly to validate the application.

  9. How do I ensure my application is processed efficiently?

    To ensure efficient processing of your application, verify all sections are completed fully and legibly, provide clear and accurate answers without using abbreviations, attach additional sheets if needed with references to the relevant questions, and ensure all signatures and dates are clearly legible. Additionally, double-check that you have included complete contact information wherever required.

Common mistakes

Filling out the Minnesota Uniform Credentialing Application meticulously is crucial for healthcare professionals seeking reappointment or credentialing. However, applicants often make several common mistakes during this process. Understanding these mistakes can help ensure the application is completed accurately, increasing the likelihood of a successful credentialing outcome. Here are eight crucial mistakes to avoid:

  1. Not providing complete contact information: It’s essential to fill out all requested contact details—including phone numbers, fax numbers, and email addresses—for education/training, past employment, hospital affiliations, and references. Incomplete information can delay the credentialing process.
  2. Using abbreviations: While it might seem more efficient, using abbreviations can lead to confusion. Applicants are advised to spell out all information fully to avoid misunderstandings or the need for clarification.
  3. Illegible signatures and dates: It’s important that all signatures and dates are clearly legible. This ensures that the application is legally binding and can be processed without delays.
  4. Failure to provide detailed employment history: Leaving gaps in the employment/practice history can raise questions about the applicant's professionalism and work ethic. It’s crucial to list all experience and explain any time gaps longer than three months.
  5. Omitting explanations for affirmative Disclosure Questions: If any of the Disclosure Questions on Pages 10 and 11 are answered affirmatively, detailed explanations must be enclosed. Neglecting this can lead to delays or even denial of credentialing.
  6. Incomplete education and training sections: Every section related to fellowship, post-graduate, or professional training must be fully completed, including dates and institution names. If the training wasn’t completed successfully, an explanation is required.
  7. Incorrectly designating practice areas: When specifying primary and sub-specialties, as well as the type of practice (e.g., primary care, specialist, locum tenens), accuracy is crucial to ensure proper credentialing for the intended scope of practice.
  8. Not verifying the accuracy and completeness of the application: Before submission, it’s wise to thoroughly review the application to ensure that all information is accurate, complete, and presented in black ink or electronically generated as required. Missing or incorrect information can significantly delay the process.

By avoiding these eight common mistakes, healthcare professionals can help streamline their credentialing process, ensuring a smoother path to reappointment or initial appointment. Remember, attention to detail and careful review of every section can make a significant difference in the application's success.

Documents used along the form

When preparing the Minnesota Uniform Credentialing Application, several other documents and forms often complement this application to ensure a comprehensive profile for credentialing or recredentialing processes. These auxiliary documents provide a complete picture of the applicant's qualifications, background, and competencies. Understanding these documents is crucial for a smooth and efficient credentialing process.

  • Curriculum Vitae (CV): A detailed document that outlines the applicant's education, work history, certifications, publications, and other professional achievements. This document offers a comprehensive look at the applicant's professional background and accomplishments.
  • Proof of Professional Liability Insurance: This document verifies that the applicant has current professional liability insurance coverage, providing details on the policy limits and the insurance provider. It's essential for demonstrating the applicant’s accountability and protection in professional practice.
  • Continuing Medical Education (CME) Certificates: These certificates evidence the completion of ongoing medical education requirements. CMEs help ensure that healthcare providers remain up-to-date with the latest knowledge and techniques in their field.
  • Board Certification Document: A document confirming the applicant's certification status with the appropriate medical board relevant to their specialty. Board certification is an indicator of the applicant's expertise and commitment to maintaining quality in their practice.

Together with the Minnesota Uniform Credentialing Application, these documents form a crucial part of the credentialing and recredentialing process, offering a rounded view of the applicant's credentials, capabilities, and readiness to provide high-quality healthcare services. Ensuring these documents are accurately completed and up-to-date facilitates a smoother verification process, ultimately benefiting both the healthcare provider and the patients they serve.

Similar forms

The Minnesota Uniform Credentialing Application form closely resembles the Medical Staff Application used by hospitals and health systems. Both require detailed personal data, professional experiences, and education. These forms gather comprehensive information to assess a practitioner’s qualifications and history for credentialing purposes. Each form is designed to ensure the applicant meets specific standards necessary for the provision of healthcare services.

Similarly, the National Provider Identifier (NPI) Application also shares characteristics with the Minnesota form. It requires personal and practice information to assign a unique identifier to healthcare providers in the United States. While the focus is on obtaining an NPI number rather than credentialing, both forms collect detailed professional information, including practice locations and specialties.

The State Medical License Application is another document bearing similarities. Like the Minnesota form, it collects detailed personal and professional information to determine eligibility for medical licensure in a particular state. Both forms are essential for practitioners to legally provide healthcare services, ensuring they have the necessary qualifications and background.

The DEA Registration Application for Practitioners also parallels the Minnesota document by requiring detailed practitioner information. This form is necessary for healthcare providers to prescribe controlled substances. While the primary purpose differs, both forms play a crucial role in regulatory compliance within the healthcare sector.

The Clinical Privileges Application found at hospitals and other healthcare facilities resembles the Minnesota form by requesting detailed professional qualifications, including education and training, to grant specific clinical privileges to healthcare providers. These forms ensure that practitioners are qualified to perform certain procedures or patient care services.

The Professional Liability Insurance Application is another similar document that gathers comprehensive personal and professional information to assess risk and provide appropriate insurance coverage for healthcare practitioners. Both forms are essential for the protection and credentialing of healthcare providers.

The Board Certification Application by various specialty boards also shares similarities with the Minnesota form. It requires detailed education and training information, alongside professional experience, to award certification. Both documents validate a healthcare provider’s expertise in a specific field.

The Continuing Medical Education (CME) Reporting Form, necessary for maintaining licensure and board certification, similarly gathers information on a practitioner’s engagement with ongoing education. While focused on educational activities rather than credentialing, it reflects a commitment to professional development like the Minnesota form.

The Visa Screening Application for healthcare workers intending to practice in the United States requires extensive personal and professional details, similar to those collected in the Minnesota form. It ensures that healthcare practitioners meet the qualifications and standards needed to provide care in a different country.

Lastly, the Provider Enrollment Form for government and private insurance programs, which necessitates detailed professional information to allow healthcare providers to bill for their services, mirrors the comprehensive nature of data collection seen in the Minnesota form. Both are critical for the integration of healthcare providers into broader systems of care and reimbursement.

Dos and Don'ts

When it comes to filling out the Minnesota Uniform Credentialing Application form, it's crucial to ensure the process is done meticulously to avoid any issues that could delay or affect your credential or reappointment. To guide you through this process, here are some essential do’s and don'ts:

Do:

  • Ensure all information is complete and accurate: Review each section of the application carefully, making sure to provide comprehensive and precise information. This includes personal details, contact information, work history, and educational background.

  • Use black ink or electronically generate your application: To maintain legibility and ensure your application is processed efficiently, either fill out the form using black ink or generate the information electronically if possible.

  • Sign and date the application where required: Your signature and the date are crucial components of the application. They validate the authenticity of the information provided. Ensure all signatures and dates are clearly legible.

  • Provide explanations for any affirmative answers to disclosure questions: If you answer 'yes' to any of the disclosure questions, it's imperative to attach clear and detailed explanations, as requested.

Don't:

  • Leave gaps in your chronology: The application requires a complete work history without any unexplained gaps. If there are periods when you were not working, provide a detailed explanation for these gaps.

  • Use abbreviations: To avoid confusion and ensure clarity, refrain from using abbreviations in your application. Spell out all terms completely.

  • Forget to attach additional sheets if necessary: If you find that the space provided on the application is not sufficient for your answers, attach additional sheets of paper. Be sure to reference the question you are answering on these additional sheets.

  • Overlook the need to verify all dates by month, day, and year: Precision is key when detailing any dates related to employment, education, or professional training. Ensure you specify the month, day, and year to avoid any uncertainty.

Misconceptions

Many healthcare professionals encounter the Minnesota Uniform Credentialing Application during their careers. However, some common misconceptions about this application process can lead to confusion and delays. It's essential to understand the truth behind these misconceptions to ensure a smooth credentialing and reappointment process.

  • Misconception 1: The application is only for physicians and dentists.

    Reality: While it may seem that the form is tailored primarily for physicians and dentists, it is also designed for allied health professionals. The application includes a section specifically for allied health professionals to provide their details, including their profession/title and information about their sponsoring or collaborative physician.

  • Misconception 2: Abbreviations are acceptable to use on the form.

    Reality: The form clearly instructs applicants not to use abbreviations. Providing full names, titles, and other information without abbreviations ensures clarity and helps avoid any misunderstandings or processing delays.

  • Misconception 3: It’s unnecessary to fill out the form legibly if attaching additional documents.

    Reality: It's crucial that the application and any attachments are filled out legibly or electronically generated. This requirement helps ensure that all information is easily readable and can be processed efficiently.

  • Misconception 4: Providing a complete history is optional.

    Reality: The application requires a comprehensive listing of professional history, including employment, practice history, and any gaps in employment. Leaving no gaps in the chronology of your professional history is vital for a thorough review and verification process.

  • Misconception 5: Contact information is only vital for current employment.

    Reality: The application requires contact information for credentialing contact, education/training references, past employment, hospital affiliations, and professional and academic affiliations. Providing complete contact information, including addresses, phone numbers, and email addresses where indicated, is crucial for the verification process.

  • Misconception 6: Email addresses are optional.

    Reality: While it might seem like a minor detail, providing a preferred email address is a requirement on the form. Email communication is a standard method for correspondence throughout the credentialing process.

  • Misconception 7: The “Time Gaps” section is only for absences from medical practice.

    Reality: Applicants must explain any gaps or interruptions in their practice or professional practice that are greater than three months since their last reappointment. This requirement includes time out of medical practice for any reason, reflecting the need for a complete professional history.

  • Misconception 8: Only primary hospital affiliations need to be detailed.

    Reality: The application requests information on all hospital affiliations since the last reappointment, not just the primary affiliation. This comprehensive history is important for understanding the applicant's full professional background and scope of practice.

Understanding and addressing these misconceptions can help applicants ensure that their Minnesota Uniform Credentialing Application is complete, accurate, and processed without unnecessary delays.

Key takeaways

Filling out the Minnesota Uniform Credentialing Application is a critical step for physicians, dentists, and allied health professionals applying for reappointment. The process demands precise attention to various details that ensure the application accurately reflects the applicant's credentials and experience. Here are four key takeaways to consider:

  • Complete and Accurate Information: It is imperative to fill out the application thoroughly and accurately, ensuring that all information, including contact details, employment history, and hospital affiliations, is up to date and complete. If additional space is needed beyond what the application provides, attaching extra sheets with a clear reference to the question being answered is essential. The use of abbreviations should be avoided to maintain clarity.
  • Legibility: All information, whether handwritten or electronically generated, must be legible. This includes signatures and dates, which must be clearly discernible. Ensuring legibility is crucial for the processing and review of the application by credentialing bodies.
  • Disclosure Questions: Applicants must answer all disclosure questions on the designated pages of the application, providing explanations for any affirmative answers. This step is critical for assessing the applicant's suitability and background for reappointment.
  • Signatures and Documentation: The application requires the applicant's signature on both the Attestation Statement and the Authorization and Release sections, along with the current date. These signatures authorize the verification of information and release pertinent data for the credentialing process. It is also important to print all information using black ink or electronically to ensure consistency and legibility.

Adhering to these guidelines is fundamental for the successful submission of the Minnesota Uniform Credentialing Application. The meticulous provision of information, combined with clear and legible documentation, facilitates a streamlined credentialing process, ultimately supporting healthcare professionals in maintaining their practice and delivering quality care.

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