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Blank Minnesota Uniform Credentialing Application PDF Template

The Minnesota Uniform Credentialing Application form serves as a comprehensive and structured document designed to streamline the credentialing and reappointment process for physicians, dentists, and allied health professionals in Minnesota. This document requests detailed information on a professional's education, training, employment history, and much more, making it a crucial step for healthcare providers seeking to maintain or establish credentials with healthcare facilities and insurance networks. To ease the transition towards simplifying your credentialing process, consider taking the necessary steps to fill out the form by clicking the button below.

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Blank Minnesota Uniform Credentialing Application PDF Template

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The Minnesota Uniform Credentialing Application form plays a crucial role in the reappointment process for physicians, dentists, and allied health professionals looking to renew their credentials. Carefully crafted to cover a wide array of information required for verifying the qualifications and backgrounds of healthcare providers, this form demands comprehensive details such as personal data, credentialing contact information, primary and additional practice locations since the last reappointment, and educational background. It stresses the importance of accuracy and legibility, indicating that everything from professional training, chronological employment or practice history, including military service, to primary hospital affiliation and details of other hospital affiliations since the last reappointment, must be clearly and thoroughly documented. Additionally, the form requires details on any languages spoken other than English, indicating a consideration for patient accessibility and care quality. With sections dedicated to explaining gaps in professional practice, the form also navigates through professional affiliations and admissions privileges, ensuring a meticulous review process for reappointment. By mandating all information be completed in black ink or electronically generated, including indispensable signatures and dates, this form underscores the meticulous nature of the credentialing process, ensuring all details are up to date and accurately reflect the applicant's current professional status.

Preview - Minnesota Uniform Credentialing Application Form

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

Download Minnesota Uniform Credentialing Application PDF Form

Form Data

Fact	Detail
Form Type	Minnesota Uniform Credentialing Application
Application Purpose	Reappointment for Physician/Dentist/Allied Health Professional
Required Information	Applicant's Name, Contact Information)
Special Section	Exclusive section for Allied Health Professionals to provide Profession/Title and Sponsoring/Collaborative Physician
Instruction Key Points	Complete legibly or electronically, avoid abbreviations, ensure signatures and dates are clear
Verification Checks	Includes checks for complete addresses, proper dating format, and disclosure question responses
Additional Attachments	Allowance for attaching extra sheets if more space is needed
Document Revisions	Document has been revised multiple times (2001-2016)

Instructions on Utilizing Minnesota Uniform Credentialing Application

Filling out the Minnesota Uniform Credentialing Application form is a critical step in the process of reappointment for physicians, dentists, and allied health professionals. The goal is to ensure that all the information provided is complete, accurate, and presented in a clear manner. Below are the steps to properly fill out the application, ensuring that the necessary details are covered, and the instructions are followed to the letter. Accuracy and attention to detail are paramount throughout this process.

Start by printing your full name (Last, First, Middle, Suffix, Title) as it appears on your state license at the top of the form.
Complete the Credentialing Contact Information section with your name, phone number, address, fax number, and email address.
If you are an Allied Health Professional, fill in the Profession/Title field and provide the name of your Sponsoring/Collaborative Physician.
Ensure all required attachments are prepared for submission, as outlined in the initial instructions, including additional sheets for extended answers and explanations for any affirmative responses to disclosure questions.
Under Personal Data, fill in all former aliases, spouse's name (optional), date of birth, gender, social security number, NPI number, current home address, preferred mailing address, preferred email address, and phone numbers. Specify if you speak other languages fluently enough to treat non-English speaking patients.
Detail your Primary or Pending Practice Location, including Clinic Name, Address, Office Phone Number, Fax Number, Federal Tax ID Number, Type II NPI, Email Address, Start Date, Practice Type, and whether you are accepting new patients, among other details.
For any Additional Practice Locations since your last reappointment, replicate the details provided for the primary location, including start dates, practice types, and specialties.
List Fellowship/Post-Graduate/Professional Training details since your last reappointment, including institution names, dates, program types, and completion status.
Document all Professional and Academic/Faculty Affiliations since the last reappointment with dates, institution names, positions, and contact information.
Provide a Chronological Employment/Practice History, including military service if applicable. Ensure no gaps in the chronology, and explain any gaps greater than three months.
For Primary Hospital Affiliation and Other Hospital Affiliations since the last reappointment, include the facility name, dates, types of privileges, department chairperson, and contact information. Explain the method for the continuity of care if you have no admitting privileges.
Ensure all sections are filled out in black ink or electronically generated as specified, checking off each instruction as you complete them to ensure nothing is missed.
Answer all Disclosure Questions honestly and provide required explanations for affirmative answers on the designated pages.
Sign and date the Attestation Signature and Date statement and the Authorization and Release statement on the respective pages.

After completing all these steps, review the application thoroughly for accuracy and completeness. Ensure that all signatures and dates are clear and legible. Submit the application along with all required attachments and additional sheets referenced in your answers to the designated recipient as per the instructions provided by the Minnesota Uniform Credentialing process.

Obtain Answers on Minnesota Uniform Credentialing Application

What is the Minnesota Uniform Credentialing Application form?

The Minnesota Uniform Credentialing Application form is a comprehensive document designed to streamline the process of credentialing for physicians, dentists, and allied health professionals in Minnesota. This form is meant to be used for reappointment purposes, ensuring that healthcare practitioners can efficiently update their credentials. It collects detailed information about the applicant's personal data, education, training, hospital affiliations, employment history, and more.

Who needs to fill out the Minnesota Uniform Credentialing Application form?

This form is intended for physicians, dentists, and allied health professionals in Minnesota who are seeking reappointment. It must be completed by those who have previously been credentialed and are in the process of renewing their credentials to continue their professional practice within the state.

What information do I need to provide on the form?

The form requires a variety of information, including but not limited to:

Personal and contact information
Education and training details
Past employment and chronological practice history
Details of hospital affiliations
Information on any additional practice locations
Languages spoken other than English
Narrative description of clinical practice and specialties

All sections, including those for disclosing any gaps in practice and the details of professional references, should be completed in full. Additional sheets can be attached if more space is needed.

Are there specific instructions for filling out the form?

Yes, the application provides clear instructions that need to be carefully followed. These include:

Completing the application legibly in black ink or electronically
Not using abbreviations
Providing complete addresses, phone numbers, fax numbers, and email addresses wherever indicated
Designating dates by month, day, and year
Signing and dating the attestation and authorization and release sections

What if I need more space than provided on the application?

If additional space is required to answer any question, you are encouraged to attach extra sheets to the application. Ensure each attachment references the question being answered for clarity.

How do I disclose language fluency on the application?

There's a specific section in the application where applicants can indicate whether they speak a language other than English with sufficient fluency to treat patients who only speak that language. You should specify the language(s) in the space provided.

What happens if I have time gaps in my employment or practice history?

The form requires you to explain any gaps or interruptions in your medical or professional practice that are greater than three months since your last reappointment. If additional space is required for explanation, you can attach a separate sheet detailing these gaps.

How do I submit my completed Minnesota Uniform Credentialing Application form?

Submission instructions are typically provided by the credentialing body or employer requesting the form. It's essential to follow their specific guidelines for submission, which may involve sending it via mail, fax, or electronically, depending on the entity's preference.

What is the importance of signing the attestation and authorization and release sections?

By signing these sections, you attest to the accuracy and completeness of the information provided in the form. You also authorize the release of this information to relevant parties for the purpose of credentialing. These signatures are crucial, as they validate the form and allow the credentialing process to proceed.

Common mistakes

Not providing complete and accurate credentialing contact information, including failing to fill in complete street addresses, phone, fax, and e-mail addresses wherever indicated. This is crucial for ensuring all background and verification checks can be efficiently carried out.
Overlooking the requirement to use black ink or electronically generated text for filling out the application. Deviating from this instruction can make the document hard to read and potentially invalid.
Using abbreviations instead of writing out information in full. This mistake can lead to misunderstandings or the need for clarification, delaying the credentialing process.
Failure to answer all of the Disclosure Questions on Pages 10 and 11, including not enclosing explanations for affirmative answers. This oversight can raise red flags or pause the review process.
Omitting signatures and dates or providing them in a manner that isn’t clearly legible. As legal attestations of the accuracy and completeness of the application, ensuring these are correct and clear is fundamental.
Neglecting to designate dates by month, day, and year for time frames, which is essential for verifying the timeline of training, employment history, and other critical dates.
Leaving gaps in the chronological employment/practice history or not providing a complete explanation for any such gaps as required. This can create concerns about the applicant’s practice history and professional continuity.

In addition to these mistakes, applicants should also:

Double-check all entries for accuracy and completeness before submission to avoid delays in processing.
Ensure that any additional sheets of paper or documents attached to the application are clearly labeled and referenced within the application to prevent loss or confusion.
Regularly follow up with the credentialing body to confirm receipt of the application and inquire about any outstanding issues or further information needed.

Documents used along the form

Completing the Minnesota Uniform Credentialing Application is a crucial step for healthcare providers in Minnesota aiming to be credentialed or recredentialed. However, this form is often just one part of a broader array of documents required to fully process a healthcare provider's credentialing or recredentialing application. Here is an overview of up to six other commonly needed documents and forms:

Curriculum Vitae (CV): A comprehensive document detailing the applicant's education, training, professional experience, and any other relevant professional activities or achievements. It provides a chronology of the applicant's career and is pivotal in assessing their qualifications.
MN Department of Human Services Provider Enrollment Application: This is required for health professionals who wish to participate in state healthcare programs. It verifies the provider's eligibility to offer services covered under these programs.
Malpractice Insurance Face Sheet: A document demonstrating the provider's current malpractice insurance coverage, including the policy number, coverage amounts, and period of coverage. It ensures the provider is adequately insured against claims.
Background Check Authorization Form: Permission for the credentialing body to perform a background check, including criminal history, to ensure the provider meets all legal and ethical standards.
DEA Certificate: For providers who prescribe controlled substances, a current Drug Enforcement Administration (DEA) certificate is mandatory, confirming their authorization to prescribe such medications.
Licensure Verification: Official document(s) confirming the provider's licensure status in the state they are applying for credentialing, including any disciplinary actions or restrictions. This might require direct verification from the state's medical board.

Beyond the Minnesota Uniform Credentialing Application, these documents collectively contribute to a comprehensive profile of the applicant, facilitating a thorough evaluation by credentialing committees. Each document plays a critical role in establishing the credentials, qualifications, and suitability of healthcare providers to deliver quality care.

Similar forms

The Minnesota Uniform Credentialing Application form shares similarities with Medical Licensure Applications used by state medical boards. Both demand detailed personal data, professional qualifications, and a comprehensive history of medical practice. These applications serve as the foundation for assessing the eligibility and qualifications of healthcare professionals to ensure public safety and high standards of medical care.
Provider Enrollment Forms for health insurance companies also bear resemblance. They require healthcare providers to furnish information about their practice locations, credentials, and services provided. This ensures that providers meet the insurance company's criteria for quality and compliance, facilitating the process by which providers join insurance networks and receive reimbursement for services rendered to insured patients.
Similarly, Hospital Privileging Forms align with the Minnesota Uniform Credentialing Application in the need to list hospital affiliations and types of admitting privileges. These forms play a crucial role in hospital credentialing processes, determining providers’ rights to admit and treat patients within hospital settings, thereby directly impacting patient care and hospital operations.
The form also parallels Continuing Medical Education (CME) Reporting Forms, which track ongoing professional development. Such documentation supports the maintenance of a healthcare professional’s knowledge and skills, reflecting their commitment to staying abreast of advancements in medical science and practice standards.
Professional Liability Insurance Applications show similarities by necessitating detailed historical professional activity and any lapses in practice. They evaluate the risk and coverage needs of healthcare professionals, ensuring adequate protection against potential malpractice claims.
Lastly, the application is akin to Clinical Privileges Applications used by healthcare institutions. These applications require detailed information about an applicant's education, training, experience, and scope of practice to ascertain their competency in performing specific clinical procedures, ensuring patient safety and care quality.

Dos and Don'ts

When completing the Minnesota Uniform Credentialing Application form, navigating the process efficiently and accurately is crucial. To aid in this, here are several dos and don'ts to keep in mind:

Do provide complete street addresses, phone, fax, and e-mail addresses wherever requested, including for your education/training, past employment, hospital affiliations, and references.
Do use black ink or ensure the information is electronically generated if you're not filling it out by hand, to maintain legibility.
Do answer all of the Disclosure Questions on Pages 10 and 11 clearly, and provide explanations for any affirmative answers, attaching additional sheets if necessary.
Do sign and date the Attestation Signature and Date statement (Page 12) and the Authorization and Release (Page 13) to validate the application.
Do ensure all signatures and dates are clearly legible to avoid delays in processing the application due to illegibility issues.
Don't leave any fields blank; if a question does not apply, indicate with "N/A" or "Not Applicable" to show that you have seen and considered the question.
Don't use abbreviations when completing the application; write all titles, names, and addresses in full to avoid any confusion or misunderstanding.
Don't provide incomplete information about your practice history; ensure you include all necessary details about each practice location and employment history, including gaps.
Don't forget to attach additional sheets if more space is needed than what is provided on the application; always reference the question you're answering on these additional sheets.

Following these guidelines will help streamline the completion of your Minnesota Uniform Credentialing Application, ensuring a smoother review process and reducing the likelihood of errors or omissions.

Misconceptions

There are several misconceptions about the Minnesota Uniform Credentialing Application form that both applicants and sometimes those involved in the credentialing process might have. Understanding these misconceptions is critical to ensure the application process is handled correctly and efficiently.

Only for Physicians and Dentists: A common misconception is that the Minnesota Uniform Credentialing Application is solely for physicians and dentists. However, allied health professionals are also required to use this form for credentialing purposes, as explicitly stated in the file instructions.
Electronic Submission is Not Allowed: Some may believe that this application must be submitted in a hard copy format. In truth, the document clarifies that all information can be printed in black ink or electronically generated, indicating that electronic submissions are acceptable and encouraged for efficiency and legibility.
Abbreviations Are Acceptable: The application instructions explicitly request not to use abbreviations. This ensures clarity and avoids any confusion that may arise from abbreviated terms that may be interpreted differently.
Signatures Can be Digital: While digital processes are increasingly becoming the norm, this application specifies that all signatures and dates must be clearly legible, implying that digital signatures might not meet this requirement, especially if they compromise legibility.
Complete Addresses Are Not Necessary: There might be an assumption that providing partial addresses or contact information is sufficient. Contrary to this belief, the form requests that complete street address, phone, fax, and email addresses be provided wherever indicated to ensure comprehensive and accurate credentialing.
Language Fluency Does Not Matter: The application seeks information about the applicant's language fluency other than English to cater to non-English speaking patients. This highlights the importance of understanding and communicating with the patient population directly.
No Need to Report Non-Medical Employment: The form requires a chronological listing of all employment/practice history since the last reappointment, including non-medical employment. This is crucial as it provides a full picture of the applicant’s professional history and gaps in practice.
Gaps in Practice Don't Need Explanation: Every gap or interruption in practice of more than three months needs to be explained. This is often overlooked but is critical for credentialing purposes to account for all time periods and ensure there are no unexplained lapses in professional activity.
Former Aliases Are Optional: Including all former aliases is mandatory as part of the personal data section to ensure comprehensive background checks and verification processes. This is not optional and is essential for an accurate credentialing process.

Understanding these misconceptions is vital for both applicants and those reviewing the applications to ensure the process is completed accurately, efficiently, and to the benefit of all parties involved.

Key takeaways

Filling out and using the Minnesota Uniform Credentialing Application form requires attentive detail to ensure a smooth credentialing process for healthcare professionals. Here are six key takeaways to guide applicants through this process:

Complete all sections thoroughly and legibly, either by hand in black ink or electronically, to avoid processing delays. Incomplete or unreadable applications can lead to significant delays in credentialing.
Do not use abbreviations. The application must be filled out with the full terms to ensure clarity and avoid misunderstandings or requests for clarification.
Ensure all signatures and dates are clear and legible. These elements are critical for the application's validity and any future verification processes.
Provide complete contact information, including street addresses, phone, fax, and email addresses, for education/training, past employment, hospital affiliations, and references. This information is vital for the thorough verification of your credentials and work history.
Disclose gaps in employment and explain any affirmative answers to the Disclosure Questions on Pages 10 and 11. Transparency about your professional history and any potential issues is crucial for a successful credentialing process.
Attach additional sheets if more space is needed to answer any questions or to provide a comprehensive view of your employment history or practice details. Ensure these attachments are clearly referenced to the question being answered on the main application form.

Following these guidelines can help ensure the application process is efficient and successful, which is an important step in securing or continuing medical practice in Minnesota. Proper attention to detail and complete disclosures are essential components of building trust with credentialing committees and healthcare facilities.

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