Minnesota Uniform Credentialing Application Template

The Minnesota Uniform Credentialing Application form is designed for physicians, dentists, and allied health professionals who are applying for reappointment. It requires comprehensive information including personal data, credentialing contact information, employment/practice history, and affiliations with hospitals or other health care facilities. The goal is to furnish all necessary details clearly, accurately, and legibly, embracing a thorough vetting process to ensure qualifications and credentials are in order. For convenience and efficiency in completing your reappointment process, kindly proceed by clicking the button below to fill out the form.

Make This Minnesota Uniform Credentialing Application Now

In the meticulously structured realm of healthcare credentialing, the Minnesota Uniform Credentialing Application form emerges as a beacon of organization and efficiency for physicians, dentists, and allied health professionals undergoing the reappointment process. Crafted with precision, this form encompasses a comprehensive suite of sections dedicated to eliciting detailed personal data, credentialing contact information, and a chronology of professional experiences and affiliations. Applicants are called upon to furnish information ranging from basic identifying details, practice locations, and language proficiencies, extending to in-depth accounts of their educational background, employment history, and hospital affiliations—each segment meticulously designed to paint a full picture of the applicant's qualifications and practice scope. The form demands a level of precision and attention to detail, mandating that all entries be printed in black ink or digitally generated, ensuring clarity and legibility. Signatures and dates, decisive in their importance, are to be unmistakably legible, underscoring the form's role in not just collecting information, but in upholding the integrity of the credentialing process. The nuanced requirements, such as explicit instructions against abbreviations and the necessity for thorough disclosure in response to specific queries, highlight the form's comprehensive nature. Designed to leave no stone unturned, the Minnesota Uniform Credentialing Application form stands as a testament to the thorough scrutineering process foundational to reappointment and aimed at ensuring practitioners meet the rigorous standards expected in healthcare.

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
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: _______________

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

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File Specifics

Fact	Detail
Form Title	Minnesota Uniform Credentialing Application
Primary Users	Physician/Dentist/Allied Health Professional
Application Purpose	Reappointment
Application Revision Dates	09/2001; 04/2002; 04/2004; 01/2006; 07/2006; 01/2007; 08/2011; 10/2016
Requirement for Completeness	Complete accuracy, legibility, black ink or electronically generated
Signature Requirement	All signatures and dates must be clearly legible
Key Components	Personal Data, Primary Practice Location, Employment/Practice History, Hospital Affiliations
Special Instructions for Certain Applicants	APRNs and PAs must specify their Sponsoring/Collaborative Physician

Guide to Using Minnesota Uniform Credentialing Application

Filling out the Minnesota Uniform Credentialing Application form is a crucial step for physicians, dentists, and allied health professionals toward reappointment or credentialing. This detailed documentation supports the verification of qualifications, ensuring that healthcare providers maintain the highest standards of care. Below is a guide to help you accurately complete this form.

Start with the Applicant Name section: Enter your name as it appears on your state license, including Last, First, Middle, Suffix, and Title.
Under CREDENTIALING CONTACT INFORMATION, provide the name, phone number, fax number, address, and email of the credentialing contact. Allied Health Professionals should also fill in their Profession/Title and the name of their Sponsoring/Collaborative Physician if applicable.
For the Instructions section, ensure that all required attachments are included, all data is legible, no abbreviations are used, and that your responses are printed in black ink or electronically generated. Confirm that all signature and date fields will be completed as instructed.
In the Personal Data segment:
- Complete your personal information, including all former aliases, spouse's name (optional), date of birth, gender, Social Security Number (SSN), the National Provider Identifier (NPI), and current home address.
- Indicate your preferred mailing address and provide your preferred email address and phone numbers.
- If applicable, specify other languages you speak fluently enough to assist patients.
For the Primary or Pending Practice Location section, provide details about your primary practice location, including the clinic name, address, phone number, fax number, Federal Tax ID Number, Type II NPI, and email address. Indicate your start date, the nature of your practice, whether you accept new patients, any requests to suppress directory information, your primary and sub-specialties, and provide a narrative description of your clinical practice and special interests.
Complete the Additional Practice Location(s) section if you practice in more than one location by providing the same range of information as for the primary practice location.
Detail your Fellowship/Post-Graduate/Professional Training since your last reappointment, including the name of the institution, dates of attendance, type of program/specialty, and contact information for the program director.
List any Professional and Academic/Faculty Affiliations held since your last reappointment, providing dates, institution names, positions held, and contact information.
Complete the Chronological Employment/Practice History, including military service, ensuring no gaps. For each position, provide the organization name, your title/position, dates of employment, reason for leaving, and contact information. Use additional sheets if necessary, as instructed on the form.
Explain any gaps or interruptions in practice of greater than three (3) months since your last reappointment, using additional pages if needed.

Detail your Primary Hospital Affiliation and other hospital affiliations since your last reappointment, including facility names, types of privilege/affiliation, department chairperson, and contact information. If you have no hospital admitting privileges, describe your method for continuity of care.

Finally, ensure that all sections requiring a signature and date are duly completed.

Once the form and all attachments are completed, review the document for accuracy and completeness before submission. Ensure that all instructions regarding signatures, dates, and legibility are followed. This thorough approach ensures that your reappointment process proceeds smoothly and efficiently, reflecting your commitment to maintaining professional standards and delivering high-quality healthcare.

Crucial Questions on This Form

Welcome to the FAQ section about the Minnesota Uniform Credentialing Application form. Here, we aim to answer some common questions to help make the application process as smooth as possible. Let's dive into the details.

What is the purpose of the Minnesota Uniform Credentialing Application form?

This form is used for the reappointment of physicians, dentists, and allied health professionals in the state of Minnesota. It collects comprehensive information about the applicant's professional qualifications, employment history, and other relevant details for the credentialing process.

Who needs to complete this form?

Physicians, dentists, and allied health professionals seeking reappointment in their respective fields within Minnesota must complete this form. It's also required for certain allied health professionals to provide information about their sponsoring or collaborative physician.

How should the information be provided on the application?

All information must be printed in black ink or electronically generated. It's essential to provide complete and accurate responses, ensure all dates are clear (month, day, and year), and avoid using abbreviations. If more space is needed than what's provided, attach additional sheets referencing the relevant question.

What should be done with the Disclosure Questions section?

The Disclosure Questions on pages 10 and 11 of the application must be answered. If you answer 'yes' to any question, include a detailed explanation. This section is crucial for evaluating the applicant's history and qualifications.

Are there any specific signing requirements?

Yes. The Attestation Signature and Date statement on page 12 and the Authorization and Release on page 13 must be signed and dated. It's vital to ensure all signatures and dates are clearly legible to avoid any delays in the credentialing process.

How should gaps in employment or professional practice be addressed?

Any gaps or interruptions in medical practice or professional practice longer than three months since the last reappointment must be explained. Use the space provided or attach additional sheets if more room is needed, ensuring to include precise dates (month, day, and year).

What steps should be taken if additional space is needed for employment history or hospital affiliations?

If the provided space is insufficient, use the Chronological Employment/Practice History Addendum (page 15) for extra employment histories or the Hospital Affiliation Addendum (page 16) for additional hospital affiliations. Ensure to check the corresponding box indicating that an addendum is attached.

Common mistakes

Completing the Minnesota Uniform Credentialing Application accurately is crucial for healthcare professionals seeking reappointment. However, mistakes can occur during this process. Understanding these errors can help applicants avoid them and ensure a smoother credentialing experience.

Not providing complete contact information: Failing to include full street addresses, phone numbers, fax numbers, and email addresses for education/training, past employment, hospital affiliations, and references.

Using abbreviations: The application explicitly requests that no abbreviations be used, yet this instruction is often overlooked.

Illegible handwriting: All information must be legible or electronically generated, a guideline that is sometimes not followed.

Incomplete answers: Leaving answers incomplete, especially in the Disclosure Questions section, can delay the process.

Unclear dates: It's important to designate dates by month, day, and year. Approximations or incorrect formats can cause confusion.

Omission of additional sheets: If more space is needed than provided on the application, additional sheets should be attached and properly referenced. Applicants often miss adding these needed details.
Failure to sign and date: The Attestation Signature and Date statement and the Authorization and Release must be signed and dated clearly, but these are occasionally left blank.

Not using black ink for printing: The instructions specify that all information must be printed in black ink or electronically generated, a directive sometimes ignored.

It is essential for applicants to carefully review their application and ensure all requirements are met. Avoiding these common mistakes not only demonstrates professionalism but also facilitates a timely review process.

Documents used along the form

When professionals fill out the Minnesota Uniform Credentialing Application, it's often just the starting point. Several other documents may be needed to complete the process thoroughly. These documents play crucial roles in verifying qualifications, experience, and legal compliance, among other critical factors in the credentialing process. Below, we'll outline some of the key forms and documents frequently used alongside the Minnesota Uniform Credentialing Application.

Copy of Current State Medical License: Verification of a valid medical license in the state of Minnesota or the state where the practitioner intends to practice.

Proof of Board Certification: Documentation showing the applicant's certification with the appropriate medical board, verifying their specialty qualifications.

Malpractice Insurance Certificate: Evidence of the practitioner's current malpractice insurance coverage, including policy limits and the policy period.

Curriculum Vitae (CV): A detailed CV that includes education, training, work history, and any other pertinent professional activities, ensuring no gaps in employment.

DEA or CDS Certificate: A current Drug Enforcement Administration or Controlled Dangerous Substances certificate, if applicable, allows the practitioner to prescribe medications.

ECFMG Certificate: For physicians who graduated from medical schools outside the United States, evidence of certification by the Educational Commission for Foreign Medical Graduates.

Professional References: Letters or forms from colleagues or supervisors who can attest to the practitioner's clinical skills, ethical standards, and professional behavior.

Continuing Medical Education (CME) Credits: Documentation proving the completion of required continuing education credits for maintaining medical licensure and board certification.

Disclosure of Health Status: A statement or medical clearance form regarding the applicant’s health status, ensuring they're capable of performing the essential functions of the position they're applying for.

Together, these documents complement the Minnesota Uniform Credentialing Application, presenting a comprehensive profile of the practitioner’s qualifications, regulatory compliance, and readiness to provide high-quality healthcare services. This thorough documentation is vital not only for credentialing purposes but also for building trust with healthcare facilities, colleagues, and patients alike.

Similar forms

The Minnesota Uniform Credentialing Application shares similarities with several other documents used within the healthcare and professional fields. One such document is the Medical Staff Application form used by hospitals to credential doctors for admitting privileges. Both ensure that applicants provide comprehensive information about their education, training, and professional history. They require detailed personal data, educational backgrounds, employment history, and professional references to assess qualifications for the position or privileges being sought.

Another comparable document is the Professional License Application used by state licensing boards across various professions. These applications, much like the Minnesota Uniform Credentialing form, collect detailed information on the applicant's educational background, prior work experience, and any certifications or special training relevant to their field. Both documents serve the purpose of vetting professionals to ensure they meet the standards required to practice in their respective fields, safeguarding public welfare.

The Credential Verification Service Application provided by various credentialing organizations also mirrors the Minnesota form in many respects. Such applications are critical for verifying the credentials of healthcare professionals who wish to practice in different states or countries. They require detailed information on education, training, licensure, and work history, similar to the Minnesota form, to ensure the validity and authenticity of the applicant's credentials.

Employment Applications for positions within healthcare organizations are also similar to the Minnesota Uniform Credentialing Application. While aimed at securing a job, these applications often require in-depth information about the applicant's education, certifications, and employment history to ensure they are qualified for the role. Both types of documents play crucial roles in the vetting process, albeit for slightly different end goals.

The National Practitioner Data Bank (NPDB) Query is another document with a similar objective to the Minnesota form. While the NPDB Query is more focused on checking for malpractice suits, disciplinary actions, and other red flags in a healthcare provider's history, it complements the credentialing application by providing a thorough background check. This ensures that only qualified and reputable professionals are credentialed and allowed to practice.

Academic Application Forms for advanced education or fellowships in the medical field also share similarities. These applications usually demand detailed academic history, professional experiences, and references – much like the Minnesota Uniform Credentialing Application. They are integral to the selection process for educational programs that further a professional's qualifications and expertise in their specialty.

Lastly, the Visa Screening Application forms used by healthcare professionals seeking to work in another country have a similar comprehensive approach to gathering personal and professional information. They require proof of education, licensure, and work experience to ensure the candidate meets the host country's standards for healthcare practice, much like the credentialing application ensures practitioners meet local standards before being allowed to practice.

Dos and Don'ts

When working on the Minnesota Uniform Credentialing Application, individuals must navigate multiple sections carefully to ensure their application is accurately and completely filled out. Here are key dos and don'ts that applicants should keep in mind during this process:

Do provide complete contact information, including street addresses, phone numbers, fax numbers, and email addresses wherever required, ensuring a reliable way for credentialing contacts to reach you.

Do answer all questions accurately, offering full disclosure. This includes the detailed sections concerning your employment history and any disciplinary actions or malpractice claims.

Do include clear and legible signatures and dates on all required sections of the form, specifically the Attestation and the Authorization and Release sections, to affirm the truthfulness and grant permission for background checks.

Do use black ink or a digital format if completing the form electronically, maintaining the requirement for clarity and legibility.

Don't use abbreviations or jargon that could make your application harder to understand or might be misconstrued by those reviewing your credentials.

Don't leave gaps in your employment history, professional practice, or education. If spaces provided are insufficient, attach additional sheets with referenced questions or statements to clarify any breaks or changes in practice.

Don't forget to provide explanations for affirmative answers to the Disclosure Questions, ensuring that you attach necessary documentation or detailed explanations for any yes answers that require further detail.

Don't overlook the importance of verifying that all information provided on the application is current and accurate, including checking for any updates to contact information or affiliations that may have changed since your last credentialing cycle.

Adhering to these guidelines will facilitate a smoother credentialing process, minimizing delays and the need for additional clarifications. It demonstrates professionalism and attention to detail, qualities that are essential for all healthcare professionals.

Misconceptions

When it comes to the Minnesota Uniform Credentialing Application, there are several misconceptions that individuals may have. Addressing these misconceptions can provide clarity and improve the process for everyone involved. Here's a list of some common misunderstandings and the truths behind them:

Only Physicians Need to Complete It: While the form mentions physicians and dentists, it's also required for allied health professionals. This broader scope ensures a uniform credentialing process across a range of healthcare providers.

The Form Can Be Filled Out in Any Ink: The instructions explicitly state that all information must be printed in black ink or electronically generated. This requirement helps maintain readability and uniformity of the applications.

Abbreviations Are Acceptable for Convenience: In contrast to this belief, the form instructions advise against using abbreviations. Full terms and titles should be used to ensure clarity and avoid any misunderstandings.

Electronic Signatures Are Not Permitted: The modern revision of this form allows for electronically generated information, implying that electronic signatures are acceptable as long as they are clear and legible.

It's Only for Reappointment Purposes: Despite being termed a "reappointment" application, this comprehensive form is crucial for initial credentialing as well, particularly in detailing professional history and affiliations.

Personal Information Is Optional: The form requests detailed personal data, including contact information and social security numbers. This information is mandatory for identity verification and background checks, making it far from optional.

Gaps in Employment Must Be Related to Medical Practice Only: The form requires explaining any gaps in professional practice or employment, regardless of the nature of the gap. This includes time taken for personal reasons, highlighting the need for a complete professional history.

Additional Sheets for Information Are Discouraged: Contrary to this belief, if more space is needed than provided on the application, attaching additional sheets is encouraged. It's important to reference the question being addressed on these sheets for clarity.

Understanding these key aspects helps in the accurate and efficient completion of the Minnesota Uniform Credentialing Application, smoothing the path for healthcare professionals as they navigate the credentialing process.

Key takeaways

When approaching the task of filling out the Minnesota Uniform Credentialing Application form for reappointment, individuals should keep the following key considerations in mind:

Accuracy and completeness are critical when filling out the application. All information provided must be legible, whether handwritten or electronically produced. If additional space is required beyond what the form provides, applicants should attach extra sheets and clearly reference the question being answered on these additional documents.

Applicants are advised against using abbreviations in their responses. This helps ensure clarity and prevent misunderstandings during the credentialing review process.

The application form requires the applicant to provide detailed contact information, including complete street addresses, phone numbers, fax numbers, and email addresses for various sections such as education, training, past employment, hospital affiliations, and references.

All signatures and dates on the application must be clearly legible. This includes signing and dating the Attestation Signature and Date statement as well as the Authorization and Release. These signatures are essential for the validity of the entire application.

The form mandates the use of black ink or electronic generation for all printed information. This requirement ensures uniformity and legibility for individuals reviewing the applications.

By meticulously adhering to these guidelines, applicants can significantly enhance the seamless processing of their credentialing application. Each step is designed to facilitate accurate record-keeping and verification processes critical for reappointment considerations.

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