Credentialed Provider Application

Information and Checklist

Prospective clinical employees are required to complete and submit an application for verification of insurability along with required supporting documentation to the Office of General Counsel (OGC).

Applicants may submit their completed application along with required supporting documentation 180 days prior to their tentative hire date. A minimum of 30 business days is required to process an application after it along with all supporting documentation is received.

Please gather the items listed below before proceeding to the next step. You will be required to attach the applicable documents to the application.
- Obtain Claim History Report(s) and Certificates of Insurance. Include ALL current and PRIOR carriers, including residency, internships, and fellowships. Even if you did not have a claim, you are still required to have a letter from each carrier attesting to no claims. Failure to attach claim histories and certificates of insurance will delay the processing of your file.
- Attached is a current copy of your Resume or Curriculum Vitae
- Attached a copy of your Mississippi Professional License.
- Attached a copy of your DEA license, if applicable.
- Attached a copy of your board certificate(s), if applicable.
If you have any concerns, questions, or need additional information,

please call 601-815-7990 or send an email to riskanalyst@umc.edu.

Credentialed Provider Application

If you have questions, please call 601-815-7990 or send an email to riskanalyst@umc.edu.
If using the save and come back feature, be sure to check your spam or junk email folder.
I. Application Information
Name *

First Name Middle Name Last Name
Maiden Name (if Applicable)
Suffix
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Are you current UMMC employee? *

Yes No
Enter UMMC Employee ID Number *
Since graduating from professional school have you worked anywhere other than UMMC? *

Yes No
Date of Birth *

Month Day Year
Date
Social Security Number *
Tentative Start Date *

Month Day Year
Date
UMMC Hiring Department *
UMMC Department Contact *

First Name Last Name
UMMC Department Contact Phone Number
Please enter a valid phone number.
UMMC Department Contact Email Address
example@example.com
Provider Type *
Other *
Upload CV/Resume *

Cancel of

II. Insurance History

Please list all current and prior professional liability carriers.

IV. Education History

If one or more of the below do not apply to you, please put N/A in the provided box.
Upload Copies of Licenses & Certifications

Cancel of

V. Licensing Information

If one or more of the below do not apply to you, please put N/A in the provided box.
DEA #
DEA Card Upload

Cancel of

XI. Supplemental Claim Information

PLEASE COMPLETE ONE FORM FOR EACH CLAIM. If space is insufficient to answer any question fully, please attach a separate sheet. Please do not leave any blanks.
Name of applicant
Name of patient involved with the claim
Date of incident from which claim resulted or which is likely to result in a claim

Month Day Year
Date
Date in which claim was made

Month Day Year
Date
Allegations made against you
Explain in detail the specifics of the incident which led or may lead to the claim
Present status of claim

Active Dismissed Dropped Closed
If closed, please provide the amount of settlement or judgement
Closed with no payment?

Yes No
Name of insurance company involved
Name(s) of other doctors and hospitals, if any, involved in the claim or suit
Please attach any additional supplemental claim information

Cancel of

XII. Declaration

By signing below, I grant permission (1) to the Company to contact third parties and (2) to third parties to release to the Company information which relates to the issuance and continuation of evidence of insurability. I represent that the information provided in this application (and attachments) and any previous applications is true. I understand (1) that the application information I provided is material to the Company; (2) that the Company is relying on this information in determining whether to issue a determination of insurability; and (3) that the Company may rescind the determination of insurability if any application contains any misrepresentation or omission with intent to deceive. Further, I agree to notify the Company of any change in the information provided.
Signature of Applicant

I understand information submitted herein becomes a part of my application and is subject to the same representations and conditions. Clear
Date *

Month Day Year
Date
Should be Empty:

I. Application Information