Credentialing Checklist

Bold bullet points are documents that need to be submitted with initial application.
  •           Current Physician Licenses (and list of any inactive state licenses)
  •           Copy of Board Certification
  •           Copy of Medical School Diploma
  •           Copy of Internship/Residency/Fellowship certificates
  •           Copy of DEA
  •           Copy of Malpractice Insurance certificates for the past 2 years
  •           Copy of ECFMG (if applicable)
  •           Copy of CME past two years
  •           Current Life Supports (BLS, ACLS, ATLS, PALS, etc)
  •           Case log procedures for the past 2 years
  •           NPDB Self Query (instructions on how to do this are attached)
  •           Current Photo- passport size in color
  •           Copy Driver’s License and social security card (color copies only)
  •           TB skin test or chest X-ray within last year (only if positive history, will need proof              along with annual questionnaire) 
  •           MMR immunization records or titer results showing immunity
  •           Hepatitis B #1, #2, #3
  •           Tdap Immunization Record (Tetanus)
  •           Influenza (Mandatory October-March)
  •           Voided Check for Direct Deposit