Cardinal Psychotherapy Clinician Credentialing Form Credentialing Information For Clinicians All information is required for credentialing application. Please do not leave any questions unanswered. First Name Middle Name Last Name Current or prior use of an alias? Yes No Phone Street Address Street Address 2 City Birth City Birth Country Are you a US Citizen? Yes No Age Email* Fluent in language other than English? Yes No Ethnicity American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander Hispanic or Latino Asian White Other Prefer Not To Say Do you want your ethnicity displayed in provider directories? Yes No Marital Status Spouse name Emergency Contact Name and Number Primary Degree (masters level) Secondary degree (bachelors) Liability Insurance Carrier Liability Insurance Policy Number Liability Insurance Expiration Date NPI Number License Name License Number License Expiration Date Special Certifications Institution where you received your counseling degree Start date of counseling masters End date for counseling masters Work History Do you have a DEA with an address in the state in which you will be practicing? If this does not apply to you, select Not Applicable. Yes No NA Has your professional license or registration ever been terminated, stipulated, restricted, limited, conditioned, suspended, revoked, refused, voluntarily relinquished or not renewed by any licensing board or any health-related agency organization Yes No Has your professional license or registration ever been investigated or is it currently being investigated and, if so, what were the results? Yes No Please mark that you have submitted the following forms Copy of Current State License to Practice Copy of Malpractice Insurance Copy of Diploma Copy of W9 Copy of Resume or Complete Work History with explanation of any gaps longer than 90 days Application Addendums Provided by Cardinal Has your DEA registration ever been revoked, suspended, limited, or conditioned in any way, or have you voluntarily relinquished your DEA registration, or is there a review pending? Yes No Has your membership, clinical privileges, or employment been denied, terminated, stipulated, restricted, limited, suspended, revoked, or not renewed by any org, 3rd party payer, clinic, or health-related agency or org, or is there a review pending? Yes No Have you ever voluntarily relinquished your membership, participation, privileges employment, license, or registration in lieu of disciplinary action, or prior to or during an investigation into professional conduct or competency? Yes No Have you ever involuntarily relinquished your membership, participation, clinical privileges or request for privileges, employment, professional license or registration? Yes No Has your membership or fellowship in any professional organization or your specialty board certification ever been voluntarily or involuntarily denied, terminated, restricted, limited, suspended or revoked? Yes No Have you ever been reprimanded, censored, or disciplined by, or have you ever been subject to a corrective action with any licensing board, peer review org, 3rd party payer, clinic,medical staff, or any health-related org? Yes No Has your participation in any private, federal or state health insurance program ever been revoked, limited or restricted, or is any investigation or proceeding with respect to any such action presently underway? Yes No Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, gross misdemeanor, misdemeanor (other than a minor traffic violation), or other offense? Yes No Have you ever been found liable, guilty or responsible for sexual impropriety or misconduct or sexual harassment with a patient, co-worker, or other? Yes No Have you ever had any professional liability claims or lawsuits brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or final judgements? If yes, enclose Malpractice Litigation and Profession Yes No Has your professional liability carrier ever refused or canceled your coverage or excluded you from performing any specific privileges within your specialty? Yes No Have you ever practiced within your profession without professional liability insurance? Yes No Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients without posing a health or safety risk to your patients? Yes No Does your use (or have you been told that your use) of alcohol or drugs affect your ability, with or without reasonable accommodation, to provide appropriate care to patients without posing a health risk to your patients? Yes No Are you currently using illegal drugs or unlawful use of prescription drugs? It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other pr Yes No Submit
