NOTICE TO ALL PHYSICIAN AND APC APPLICANTS
Once an applicant has been hired and has signed an Employment Agreement, a request for Credentialing information will be sent to the applicant. Upon receipt of this information:
The following information may be requested from the On-boarding Clinician once you are hired:
___ Current Colorado License
___ Current Colorado DEA (DEA must have Colorado Address before your file is complete for Committee)
___ CAQH completed & attested per above highlighted information
___ User name & password to CAQH, once completed
___ Signature pages for your Colorado Application (complete the questionnaires & sign and date –This will be emailed to you)
___ Signature pages for Medicare enrollment - 855 I & R forms (These will be sent to you via email.
___ Signature page for Tricare enrollment (sign and date page 8 - PDF attached)
___ Professional Liability Insurance certificate of coverage from malpractice insurance carrier from last employer.
___ Medicaid and Medicare Number (if you have this already)
___ Certificate of Medical School (copy of all certificates)
___ Certificate of Board certifications (copy of all certificates)
___ Copy of all Diplomas for Graduate accredited program in specialty practice(s)
___ Curriculum Vitae
___ CME’s (copy of certificates)
___ Copy of BLS/ACLS/PALS/NRP etc.
___ Copy of DD-214 (military discharge) - if applicable
___ Copy of Driver’s License
___ Copy of Passport, if born out of US borders
___ City & State you were born in
___ DOB and SS#