MC-5
DEC 05 Page 1 of 14 Pages.
New Jersey Universal Physician Application
(Please type or print)
SECTION 1
Personal Information
Physician Name (Last) (First) (MI) (Jr., Sr., etc.)
Professional Degree(s) (MD, DO,
DDS, DMD, DPM, DC)
Social Security Number
Other Name Used
Years Associated with
Former Name
Other Name Used
Years Associated with
Former Name
Date of Birth (mm/dd/yyyy)
/ /
Gender
Male Female
Are you eligible to work in the United States?
Yes No
Home Mailing Address
City
State
Zip Code
Practice Location Information
Type of Service Provided
Primary Care Specialist Non-Primary Care Specialist
Physician Group Name/Practice Name (to appear in the directory)
Group/Corporate Name (as it appears on W-9), if different from Group
Name/Practice Name
Primary Office Mailing Address
City
State
Zip Code
Primary Office Telephone No.
Primary Office Fax No.
Primary Office E-mail Address
Tax ID Number and Associated Individual Group Number and Name for This Location
Are you currently practicing at the above location?
Yes No
If No, what is your expected start date?
Other Office Street Address
City
State
Zip Code
Telephone No.
Fax No.
E-mail Address
Do you want this site listed in the Directory?
Yes No
Tax ID Number and Associated Individual Group Number and Name for This Location
Other Office Street Address
City
State
Zip Code
Telephone No.
Fax No.
E-mail Address
Do you want this site listed in the Directory?
Yes No
Tax ID Number and Associated Individual Group Number and Name for This Location
Correspondence Office Street Address
City
State
Zip Code
Telephone No.
Fax No.
E-mail Address
If you have additional offices, please submit an attachment containing the above information and check this box:
MC-5
DEC 05 Page 2 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
License and Other Identification Numbers
(License Information - Include all license(s) and certifications in all States where you are currently or have previously been licensed.)
Type
State(s) of
Registration
Do You Currently
Practice In This State?
License/Certificate
Number
Expiration
Date
N/A
License
Yes No
License
Yes No
DEA Registration Certificate
Yes No
CDS Registration Certificate
Yes No
Other (CDS/DEA) (Specify)
Yes No
UPIN
National Provider ID
(when available)
Are you a participating
Medicare Provider?
Medicare Provider No.
Are you a participating
Medicaid Provider?
Medicaid Provider No.
International Medical Graduates: Are you certified by the Educational
Council for Foreign Medical Graduates (ECFMG)?
Yes No
If yes, ECFMG Number
ECFMG Issue Date
Medical Education
School Issuing Professional Degree (Medical, Dental, Chiropractic)
Degree
Attendance Dates
Address
City
State/Country
Zip Code
If you have attended additional schools, please submit an attachment containing the above information and check this box:
Post-Graduate Education
Internship Fellowship
Residency Teaching Appointment
Institution Name
Address
City
State
Zip Code
Specialty
Start Date (Month/Year)
End Date (Month/Year)
Post-Graduate Education
Internship Fellowship
Residency Teaching Appointment
Institution Name
Address
City
State
Zip Code
Specialty
Start Date (Month/Year)
End Date (Month/Year)
Post-Graduate Education
Internship Fellowship
Residency Teaching Appointment
Institution Name
Address
City
State
Zip Code
Specialty
Start Date (Month/Year)
End Date (Month/Year)
If you completed additional training, please submit an attachment containing the above information and check this box:
Other Graduate Level Education for Which a Degree Was Obtained -
Type of Program (Psychology, Public Health, MBA, etc.)
Institution Name
Address
City
State
Zip Code
Degree Obtained
Date of Graduation (Month/Year)
MC-5
DEC 05 Page 3 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Professional/Medical Specialty Information
Primary Specialty
Board Certified?
Yes No
Name of Certifying Board
Initial Certification Date
Recertification Date (s) (if applicable)
Expiration Date (if applicable)
If not Board Certified, indicate an
y
of the followin
g
that a
pp
l
y
:
I have taken exam, results pending for:
(board)
I am intending to sit for the Boards on:
(date)
I am not planning to take the Boards.
Do you wish to be listed in the directory under this specialty?
HMO
Yes No
PPO
Yes No
POS
Yes No
Secondary Specialty
Board Certified?
Yes No
Name of Certifying Board
Initial Certification Date
Recertification Date (s) (if applicable)
Expiration Date (if applicable)
If not Board Certified, indicate an
y
of the followin
g
that a
pp
l
y
:
I have taken exam, results pending for:
(board)
I am intending to sit for the Boards on:
(date)
I am not planning to take the Boards.
Do you wish to be listed in the directory under this specialty?
HMO
Yes No
PPO
Yes No
POS
Yes No
Additional Specialty
Board Certified?
Yes No
Name of Certifying Board
Initial Certification Date
Recertification Date (s) (if applicable)
Expiration Date (if applicable)
If not Board Certified, indicate an
y
of the followin
g
that a
pp
l
y
:
I have taken exam, results pending for:
(board)
I am intending to sit for the Boards on:
(date)
I am not planning to take the Boards.
Do you wish to be listed in the directory under this specialty?
HMO
Yes No
PPO
Yes No
POS
Yes No
List Additional Areas of Professional Practice, Interest or Focus (HIV/AIDS, etc.)
Hospital Affiliations and Privileges
Do you have hospital privileges?
Yes No
If you do not admit patients, what admitting arrangements do you have?
If you have privileges, please complete the section below. Include all hospitals where you have privileges.
Primary Hospital where you have Admitting Privileges
Telephone Number
Address
City
State
Zip Code
Full Unrestricted Privileges
Yes No
Type of Privileges
Are Privileges Temporary?
Yes No
Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?
Other Hospital Where you Have Privileges
Telephone Number
Address
City
State
Zip Code
Full Unrestricted Privileges
Yes No
Type of Privileges
Are Privileges Temporary?
Yes No
Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?
Other Hospital Where you Have Privileges
Telephone Number
Address
City
State
Zip Code
Full Unrestricted Privileges
Yes No
Type of Privileges
Are Privileges Temporary?
Yes No
Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?
Additional Hospital Where you Have Privileges
Telephone Number
Address
City
State
Zip Code
Full Unrestricted Privileges
Yes No
Type of Privileges
Are Privileges Temporary?
Yes No
Of the total admissions to all hospitals in the
past year, what percentage is to this specific
hospital?
If you have additional hospital affiliations, please submit an attachment containing the above information and check this box:
MC-5
DEC 05 Page 4 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
List all other hospitals where you have previously had privileges.
Hospital Name
Dates of Affiliation
Address
City
State
Zip Code
Hospital Name
Dates of Affiliation
Address
City
State
Zip Code
If you have other previous hospital affiliations, please submit an attachment containing the above information and check this box:
Work History
Include chronological work history since completion of training.
Practice/Employer Name
Start Date/End Date
Address
City
State
Zip Code
Practice/Employer Name
Start Date/End Date
Address
City
State
Zip Code
Practice/Employer Name
Start Date/End Date
Address
City
State
Zip Code
Practice/Employer Name
Start Date/End Date
Address
City
State
Zip Code
For additional work history, please submit an attachment containing the above information and check this box:
Please provide an explanation of any gaps greater than six months in each work history.
Date
Explanation
Date
Explanation
Are you currently on active military duty or on military reserve?
Yes No
References
Please provide three professional references that are not partners in your own group practice and are not relatives.
Name
Street Address
City, State, Zip Code
MC-5
DEC 05 Page 5 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Professional Liability Insurance Coverage
Are you self-insured?
Yes No
Name of Current Malpractice Insurance Carrier or Self-Insured Entity
Telephone Number
Effective Date
Expiration Date
Address
City
State
Zip Code
Policy Number
Amount of Coverage per Occurrence
Amount of Coverage Aggregate
Type of Coverage
Individual
Shared
Length of Time with
Carrier
Name of Previous Malpractice Insurance Carrier or Self-Insured Entity
Telephone Number
Effective Date
Expiration Date
Address
City
State
Zip Code
Policy Number
Amount of Coverage per Occurrence
Amount of Coverage Aggregate
Type of Coverage
Individual
Shared
Length of Time with
Carrier
Status/Role in Practice
Owner Partner Employee Officer Shareholder
Interests in Outside Clinical Lab(s)
If you own/co-own, or have interests in any other outside clinical lab, please fill in below:
Legal Billing Name
TIN (Attach copy of W-9)
Clinical Description
Please provide a summary pattern for this business:
Office Coverage
List names of colleague(s) providing regular coverage and his/her specialty(ies).
Name Provider Specialty
Partners
List full names of all partners in your practice (attach list for large group).
Name (Last, First, MI) Name (Last, First, MI)
MC-5
DEC 05 Page 6 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Other Practice Information (specify for each site)
Site 1 Site 2
Office Address:
Office Address:
Type of Practice:
Solo Single Specialty Group Multi-Specialty Group
Type of Practice:
Solo Single Specialty Group Multi-Specialty Group
Office Manager or Business Office Staff Contact:: Office Manager or Business Office Staff Contact::
Name:
Name:
Telephone No.:
Telephone No.:
Fax No.:
Fax No.:
Credentialing Contact (if different from above): Credentialing Contact (if different from above):
Name:
Name:
Telephone No.:
Telephone No.:
Fax No.:
Fax No.:
E-mail:
E-mail:
Address:
Address:
City:
City:
State:
Zip:
State:
Zip:
Billing Information: Billing Information:
Billing Rep. Name:
Billing Rep. Name:
Address:
Address:
City:
City:
State:
Zip:
State:
Zip:
Telephone No.:
Telephone No.:
Fax No.:
Fax No.:
E-mail:
E-mail:
Dept. Name if Hosp.-Based:
Dept. Name if Hosp.-Based:
Check should be payable to
Check should be payable to
Do you have capability of electronic billing? Yes No Do you have capability of electronic billing? Yes No
Office Business Hours (hours patients are seen): Office Business Hours (hours patients are seen):
Day
No
Office
Hours
Morning Afternoon Evening Day
No
Office
Hours
Morning Afternoon Evening
MON MON
TUES TUES
WED WED
THUR THUR
FRI FRI
SAT SAT
SUN SUN
After hours, back office phone number
for health plan business use only:
After hours, back office phone number
for health plan business use only:
Do you provide 24 hour/7 day a
week phone coverage for this site?
Yes No
If yes, indicate type:
Answering service
Voice mail with instructions to call answering service
Voice mail with other instructions
Do you provide 24 hour/7 day a
week phone coverage for this site? Yes No
If yes, indicate type:
Answering service
Voice mail with instructions to call answering service
Voice mail with other instructions
(Continue on next page.)
MC-5
DEC 05 Page 7 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Other Practice Information (specify for each site)
(Continued from previous page.)
Site 1, Continued Site 2, Continued
Do you accept new patients into the practice? ..... Yes No
-All new patients?...............................................
Yes No
-Existing patients with change of payor?............
Yes No
-New patients from physician referral?...............
Yes No
-New Medicare patients? ...................................
Yes No
-New Medicaid patients?....................................
Yes No
Do you accept new patients into the practice? .....
Yes No
-All new patients?...............................................
Yes No
-Existing patients with change of payor?............
Yes No
-New patients from physician referral?...............
Yes No
-New Medicare patients? ...................................
Yes No
-New Medicaid patients?....................................
Yes No
If this information varies by health plan, provide explanation:
If this information varies by health plan, provide explanation:
Are there any practice limitations? Yes No
If
y
es, indicate limitations below:
Are there any practice limitations?
Yes No
If
y
es, indicate limitations below:
Gender: Male Only Female Only N/A Gender: Male Only Female Only N/A
Patient Age Limitation (List Ages): N/A Patient Age Limitation (List Ages): N/A
List Other Limitations: List Other Limitations:
Do mid-level practitioners such as nurse
practitioners, physician assistants, midwives,
social workers or other non-physician providers
care for patients in your practice?
Yes No
If yes, provide the following information for each staff member:
Do mid-level practitioners such as nurse
practitioners, physician assistants, midwives,
social workers or other non-physician providers
care for patients in your practice? Yes No
If yes, indicate limitations below:
Name:
Name:
Professional Designation:
Professional Designation:
State License Number:
State License Number:
Name:
Name:
Professional Designation:
Professional Designation:
State License Number:
State License Number:
Please attach a list of any additional mid-level practitioners. Please attach a list of any additional mid-level practitioners.
Non-English Languages spoken: Non-English Languages spoken:
by health care professional:
by health care professional:
by office personnel:
by office personnel:
Are interpreters available? Yes No Are interpreters available? Yes No
If yes, specify languages: If yes, specify languages:
Does this office meet ADA
accessibility standards?
Yes No
Does this office meet ADA
accessibility standards? Yes No
Does this site provide handicapped accessibility for each of the
following:
Building Yes No
Parking
Yes No
Restroom
Yes No
Does this site provide handicapped accessibility for each of the
following:
Building
Yes No
Parking
Yes No
Restroom
Yes No
Other:
Other:
Does this site have other services for the disabled?
Yes No
If yes, indicate type:
Text Telephony - TTY
Yes No
American Sign Language-ASL
Yes No
Mental/Physical Impairment Services
Yes No
Does this site have other services for the disabled?
Yes No
If yes, indicate type:
Text Telephony - TTY
Yes No
American Sign Language-ASL
Yes No
Mental/Physical Impairment Services
Yes No
Other:
Other:
(Continue on next page.)
MC-5
DEC 05 Page 8 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Other Practice Information (specify for each site)
(Continued from previous page.)
Site 1, Continued Site 2, Continued
Is this site accessible by public transportation?
Yes No
Bus
Yes No
Subway
Yes No
Re
g
ional Train Yes No
Is this site accessible by public transportation?
Yes No
Bus
Yes No
Subway
Yes No
Re
g
ional Train Yes No
Other:
Other:
Does this site provide childcare services? Yes No Does this site provide childcare services? Yes No
Does this office qualify
as a minority business enterprise?
Yes No
Does this office qualify
as a minority business enterprise? Yes No
Do you or does someone in your office have the following
certifications?
(
Indicate for each office location.
)
Do you or does someone in your office have the following
certifications?
(
Indicate for each office location.
)
Yes No Exp.Date Yes No Exp.Date
BLS (Basic Life Support)
BLS (Basic Life Support)
ACLS (Advanced Cardiac Life Support)
ACLS (Advanced Cardiac Life Support)
ALSO (Advanced Life Support in OB)
ALSO (Advanced Life Support in OB)
PALS (Pediatric Advanced Life Support)
PALS (Pediatric Advanced Life Support)
ATLS (Advanced Trauma Life Support)
ATLS (Advanced Trauma Life Support)
NALS (Neonatal Advanced Life Support)
NALS (Neonatal Advanced Life Support)
CPR (Cardio-Pulmonary Resuscitation)
CPR (Cardio-Pulmonary Resuscitation)
Does your site provide any of the following services on site?
(
Indicate for each office location.
)
Does your site provide any of the following services on site?
(
Indicate for each office location.
)
Laboratory Services Yes No Laboratory Services Yes No
Certificate of Participation from CLIA or
another accrediting/certifying program
[AAFP, COLA, CAP, Medical Laboratory
Evaluation (MLE)] Program
Yes No
Certificate of Participation from CLIA or
another accrediting/certifying program
[AAFP, COLA, CAP, Medical Laboratory
Evaluation (MLE)] Program Yes No
If yes, list program:
If yes, list program:
Radiology Services Yes No Radiology Services Yes No
X-Ray Certification Yes No X-Ray Certification Yes No
If yes, include type:
If yes, include type:
EKG’s Yes No EKG’s Yes No
Care of Minor Lacerations Yes No Care of Minor Lacerations Yes No
Pulmonary Function Testing Yes No Pulmonary Function Testing Yes No
Allergy Injections Yes No Allergy Injections Yes No
Allergy Skin Testing Yes No Allergy Skin Testing Yes No
Office Gynecology (Routine Pelvic/Pap) Yes No Office Gynecology (Routine Pelvic/Pap) Yes No
Drawing Blood Yes No Drawing Blood Yes No
Age Appropriate Immunizations Yes No Age Appropriate Immunizations Yes No
Flexible Sigmoidoscopy Yes No Flexible Sigmoidoscopy Yes No
Tympanometry/Audiometry Screening Yes No Tympanometry/Audiometry Screening Yes No
Asthma Treatment Yes No Asthma Treatment Yes No
Osteopathic Manipulation Yes No Osteopathic Manipulation Yes No
IV Hydration/Treatment Yes No IV Hydration/Treatment Yes No
Cardiac Stress Tests Yes No Cardiac Stress Tests Yes No
Physical Therapy Yes No Physical Therapy Yes No
Additional Office Procedures Provided (incl. surgical procedures)
Additional Office Procedures Provided (incl. surgical procedures)
Is anesthesia administered in your office? Yes No
If Yes, what class or category of anesthesia do you use?
Is anesthesia administered in your office? Yes No
If Yes, what class or category of anesthesia do you use?
Who administers it? Who administers it?
For additional office sites, please submit an attachment containing the above information and check this box:
MC-5
DEC 05 Page 9 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Patient Scheduling
What is patient wait time for emergency care? .................................................
What is patient wait time for urgent care?.........................................................
What is patient wait time for symptomatic care?...............................................
What is patient wait time for scheduling routine visits?.....................................
What is patient wait time for scheduling routine care?......................................
What is average wait time for patients between waiting room and examination?
What is average wait time in minutes for returning a patient’s call?..................
Required Attachments or Supplemental Information
Please attach hard copy or scanned documents of the following:
♦ Copy(ies) of DEA registration certificate(s)
♦ Copy of state Controlled Dangerous Substance (CDS) registration
certificate(s)
♦ Copy of current professional liability insurance policy face sheet,
showing expiration dates, limits and provider’s name
♦ Copy(ies) of W-9(s) for verification of each tax identification number
used
♦ Copy of workers compensation certificate of coverage, if applicable
SECTION 2 - DISCLOSURE QUESTIONS
Please answer each question and include an explanation for any question answered “Yes.”
Licensure
1. Has your license to practice, in your profession, ever been denied, suspended, revoked,
restricted, voluntarily surrendered while under investigation or have you ever been subject to
a consent order, probation or any conditions or limitations by any state licensing board?................... Yes No
2. Have you ever received a reprimand or been fined by any state licensing board?.............................. Yes No
Hospital Privileges and Other Affiliations
3. Have your clinical privileges at any hospital or healthcare institution ever been denied,
suspended, revoked, restricted, denied renewal or subject to probationary or to other
disciplinary conditions (for reasons other than non-completion of medical records when
quality of care was not adversely affected) or have proceedings toward any of those ends
been instituted or recommended by any hospital or healthcare institution, medical staff or
committee, or governing board?..........................................................................................................
Yes No
4. Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while
under investigation?.............................................................................................................................
Yes No
5. Have you ever been terminated for cause or not renewed for cause from participation, or
been subject to any disciplinary action, by any managed care organizations (including HMOs,
PPOs, or provider organizations such as IPAs, PHOs)? .....................................................................
Yes No
Education, Training and Board Certification
6. Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked
to resign during an internship, residency, fellowship, preceptorship or other clinical education
program? If you are currently in a training program, have you been placed on probation,
disciplined, formally reprimanded, suspended or asked to resign? .....................................................
Yes No
7. Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated
your status as a student or employee in any internship, residency, fellowship, preceptorship,
or other clinical education program?.................................................................................................... Yes No
8. Have any of your board certifications or eligibility ever been revoked? ...............................................
Yes No
9. Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s)
while under investigation? ...................................................................................................................
Yes No
MC-5
DEC 05 Page 10 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
DEA or CDS Certification/Authorization
10. Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s)
or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or
voluntarily relinquished? ...................................................................................................................... Yes No
Medicare, Medicaid or Other Governmental Program Participation
11. Have you ever been disciplined, excluded from, debarred, suspended, reprimanded,
sanctioned, censured, disqualified, subject to a recovery action or otherwise restricted in
regard to participation in the Medicare or Medicaid program, or in regard to other federal or
state governmental health care plans or programs?............................................................................
Yes No
Other Sanctions or Investigations
12. Are you currently or have you ever been the subject of an investigation by any hospital,
licensing authority, DEA or CDS authorizing entities, education or training program, Medicare
or Medicaid program, or any other private, federal or state health program? ...................................... Yes No
13. To your knowledge, has information pertaining to you ever been reported to the National
Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?.........................................
Yes No
14. Have you ever received sanctions from or been the subject of investigation by any regulatory
agencies (e.g., CLIA, OSHA, etc.)?....................................................................................................
Yes No
15. Has a patient, employee, or co-worker ever accused you of sexual harassment or other
illegal misconduct that resulted in an investigation, sanction or other formal action?..........................
Yes No
16. Have you ever been investigated, sanctioned, reprimanded or cautioned by a military
hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by
a hospital or healthcare facility of any military agency?.......................................................................
Yes No
Professional Liability Insurance Information and Claims History
17. Has your professional liability coverage ever been cancelled, restricted, declined or not
renewed by the carrier based on your individual liability history? ........................................................
Yes No
18. Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by
your professional liability insurance carrier, based on your individual liability history? ........................
Yes No
Malpractice Claims History
19. Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated,
mediated or litigated)? If yes, provide information for each case on the attached form located
at the end of the Disclosure questions (list all separately)................................................................... Yes No
For any malpractice actions, please complete addendum and check this box:
Criminal/Civil History
(Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or credentialing
organization based upon all relevant circumstances, including the nature of the crime.)
20. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled
nolo contendere to any felony, crime or other offense in the last ten years or been found
liable or responsible for or named as a defendant in any civil offense that is reasonably
related to your qualifications, competence, functions, or duties as a medical professional? ...............
Yes No
21. Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled
nolo contendere to any felony, crime or other offense in the last ten years or been found
liable or responsible for or been named as a defendant in any civil offense that alleged fraud,
an act of violence, child abuse or a sexual offense or sexual misconduct?.........................................
Yes No
22. Have you ever been court-martialed for actions related to your duties as a medical
professional? .......................................................................................................................................
Yes No
MC-5
DEC 05 Page 11 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Ability to Perform Job
23. Are you currently engaged in the illegal use of drugs? (“Currently" means sufficiently recent
to justify a reasonable belief that the use of drugs may have an ongoing impact on one’s
ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks
before the date of application, rather that it has occurred recently enough to indicate the
individual is actively engaged in such conduct. “Illegal use of drugs” refers to drugs whose
possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. §
812.22 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
provision of Federal law.” The term does include, however, the unlawful use of prescription
controlled substances.)........................................................................................................................
Yes No
24. Do you use any chemical substances that would in any way impair or limit your ability to
practice medicine and perform the functions of your job with reasonable skill and safety? .................
Yes No
25. Do you have any reason to believe that you would pose a risk to the safety or well being of
your patients?......................................................................................................................................
Yes No
26. Are you able to perform the essential functions of a practitioner in your area of practice with
or without reasonable accommodation? ..............................................................................................
Yes No
Please provide information below for Malpractice Actions indicated for Disclosure Question #19.
Date of occurrence:
Date claim was filed:
Claim/case status:
Professional liability carrier involved:
Address:
Telephone Number:
Policy Number:
Amount of award or settlement and amount paid:
Method of resolution:
Dismissed Settled (with prejudice) Settled (without prejudice)
Judgment for defendant(s) Judgment for plaintiff(s) Mediation or arbitration
Description of allegations:
Were you primary defendant or co-defendant?
Number of other co-defendants:
Your involvement in case (attending, consulting, etc.):
Description of alleged injury to the patient:
To the best of your knowledge, is this case included in the National Practitioner Data Bank (NPDB)?
Yes No
MC-5
DEC 05 Page 12 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Please provide information below for any Disclosure Questions in Section II answered “Yes.”
Question
No.
Explanation
Provider Initials:
Date:
MC-5
DEC 05 Page 13 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
SECTION 3 - AUTHORIZATION, ATTESTATION AND RELEASE
I understand and agree that, as part of the credentialing application process for participation and/or clinical
privileges (hereinafter, referred to as “Participation”) at or with
(indicate managed care company(s) to which you are applying) (hereinafter, individually referred to as the
“Entity”), and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a
proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status,
character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for
Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information
obtained relating to the application process will be held confidential to the extent permitted by law.
I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each
independently. I further acknowledge and understand that my cooperation in obtaining information and my
consent to the release of information do not guarantee that any Entity will grant me clinical privileges or contract
with me as a provider of services. I understand that my application for Participation with the Entity is not an
application for employment with the Entity and that acceptance of my application by the Entity will not result in my
employment by the Entity.
Authorizations
Investigation Concerning Application for Participation: I hereby authorize the following individuals including,
without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity’s affiliated
entities and their representatives, employees, and/or designated agents; and the Entity's designated professional
credentials verification organization (collectively referred to as “Agents”), to investigate information, which
includes both oral and written statements, records, and documents, concerning my application for Participation. I
agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation.
Third-Party Sources to Release Information Concerning Application for Participation: I authorize any third
party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification,
corporations, companies, employers, former employers, hospitals, health plans, health maintenance
organizations, managed care organizations, law enforcement or licensing agencies, insurance companies,
educational and other institutions, military services, medical credentialing and accreditation agencies, professional
medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health
Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including
otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical
competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or
chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing
on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability
carrier(s) to release my history of claims that have been made and/or are currently pending against me. I
specifically waive written notice from any entities and individuals who provide information based upon this
Authorization, Attestation and Release.
Release and Exchange of Disciplinary Information: I hereby further authorize any third party at which I
currently have Participation or had Participation and/or each third party’s agents to release “Disciplinary
Information,” as defined below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release
Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have
Participation, and as may be otherwise required by law. As used herein, “Disciplinary Information” means
information concerning: (i) any action taken by such health care organizations, their administrators, or their
medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a
corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the
employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the
commencement of formal charges, but after I have knowledge that such formal charges were being (or are being)
contemplated and/or were (or are) in preparation.
Provider Initials:
Date:
MC-5
DEC 05 Page 14 of 14 Pages.
NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)
Releases
Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third
party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or
willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and
exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release.
I further agree not to sue any Entity, any Agent(s), or any other third party for their acts, defamation or any other
claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third
party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit,
any other applicable immunities provided by law for peer review and credentialing activities.
In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party
include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its
affiliates or agents retains the right to allow access to the application information for purposes of a credentialing
audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing
processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement.
I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which
I am an applicant for Participation at an Entity, a member of an Entity's medical or health care staff, or a
participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the
application of this irrevocable authorization. I understand that my failure to promptly provide another consent may
be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and
regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I
agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is
not and will not be a violation of my privacy.
Attestation
I certify that all information provided by me in my application is true, correct, and complete to the best of my
knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to
the information I have provided in my application or authorized to be released pursuant to the credentialing
process. I understand that corrections to the application are permitted at any time prior to a determination of
Participation by the Entity, and must be submitted on-line or in writing, and must be dated and signed by me (may
be a written or an electronic signature). I understand and agree that the information provided on this application
may be shared with appropriate State and federal agencies.
I understand and agree that any material misstatement or omission in the application may constitute grounds for
withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate
suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s). I further
understand and agree that submitting false, misleading or incomplete information may result in the imposition of
administrative, civil and/or criminal sanctions, in accordance with State and federal law.
I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I
understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as
effective as the original.
Name (Print or Type)
Social Security Number
Signature
Date
