Oklahoma Credentialing Application
Section 1 of 14: Personal Information
Name of organization application will be submitted to:
Today's Date:
/
Month
/
Day
Year
Date
Name:
*
First Name
Middle Name
Last Name
Suffix
Profession Degree:
*
Please Select
D.M.D.
D.D.S.
M.D.
Gender:
*
Male
Female
Have you been known by another name?
*
Yes
No
Other Name:
*
First Name
Middle Name
Last Name
Suffix
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Have you been known by any another name?
*
Yes
No
Other Name:
*
First Name
Middle Name
Last Name
Suffix
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Social Security Number:
*
Do you have a NPID (formerly UPIN) number?
*
Yes
No
NPID (formerly UPIN):
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Place of Birth:
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Citizenship:
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Visa Type:
*
Visa Number:
*
Expiration Date:
*
-
Month
-
Day
Year
Date
Please upload Visa:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a Medicare or Medicaid Number?
*
Yes
No
Medicare Number:
*
Medicaid Number:
*
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Oklahoma Credentialing Application
Section 2 of 14: Directory Information
Credentialing Correspondence:
Mailing Address for all Credentialing Correspondence:
*
Street Address
Suite Number
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number for all Credentialing Correspondence:
*
Please enter a valid phone number.
Fax Number for all Credentialing Correspondence:
*
Please enter a valid phone number.
Emergency/Pager Number for all Credentialing Correspondence:
*
Please enter a valid phone number.
Answering Service Number for all Credentialing Correspondence:
*
Please enter a valid phone number.
Email for all Credentialing Correspondence:
*
example@example.com
Contact Person For Credentialing Correspondence:
*
First Name
Last Name
Office Information:
Office Street Address:
*
Street Address
Suite Number
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Office Phone Number:
*
Please enter a valid phone number.
Office Fax Number:
*
Please enter a valid phone number.
Office Emergency/Pager Number:
*
Please enter a valid phone number.
Answering Service Number:
*
Please enter a valid phone number.
Office Email:
*
example@example.com
Is the information above the same for mailing address?
*
Yes
No
Office Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Office Mailing Phone Number:
*
Please enter a valid phone number.
Office Mailing Fax Number:
*
Please enter a valid phone number.
Office Mailing Emergency/Pager Number:
*
Please enter a valid phone number.
Office Mailing Answering Service Number:
*
Please enter a valid phone number.
Office Mailing Email:
*
example@example.com
Is the information above the same for billing address?
*
Yes
No
Billing Address:
*
Street Address
Suite Number
City
State
Zip Code
Billing Phone Number:
*
Please enter a valid phone number.
Billing Fax Number:
*
Please enter a valid phone number.
Billing Emergency/Pager Number:
*
Please enter a valid phone number.
Billing Answering Service Number:
*
Please enter a valid phone number.
Billing Email:
*
example@example.com
Is the information above the same for claims payment address?
*
Yes
No
Claims Payment Address:
*
Street Address
Suite Number
City
State
Zip Code
Claims Payment Phone Number:
*
Please enter a valid phone number.
Claims Payment Fax Number:
*
Please enter a valid phone number.
Claims Payment Emergency/Pager Number:
*
Please enter a valid phone number.
Claims Payment Answering Service Number:
*
Please enter a valid phone number.
Claims Payment Email:
*
example@example.com
Make Checks Payable To:
*
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Oklahoma Credentialing Application
Section 3 of 14: Current Professional Practice
Primary Specialty (or field of practice):
Subspecialty:
Percent of Time:
Do you have a secondary specialty?
Yes
No
Secondary Specialty:
Subspecialty:
Percent of Time:
Do you wish to be listed as:
Primary Care Provider
Specialist
Hospitalist
On-Call
Other
Are you a primary care physician?
Yes
No
List special diagnostic or treat procedures performed in your office(s):
Are you accepting new patients?
*
Yes
No
Are you willing, in the future to accept new patients?
*
Yes
No
Do you admit your own patients to hospitals?
*
Yes
No
Are you willing to accept current patients if they convert to the healthcare plan to which you are applying?
*
Yes
No
Are you a member of an Independent Practice Association or a Physician Hospital Association?
*
Yes
No
Name of Independent Practice Association or a Physician Hospital Association:
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Fax Number:
*
Please enter a valid phone number.
Answering Service Number:
*
Please enter a valid phone number.
Do you have another Independent Practice Association or a Physician Hospital Association to enter?
Yes
No
Name of Independent Practice Association or a Physician Hospital Association:
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Fax Number:
*
Please enter a valid phone number.
Answering Service Number:
*
Please enter a valid phone number.
List any restrictions on your practice (i.e. patient age and gender):
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Oklahoma Credentialing Application
Section 4 of 14: Education
Medical/Dental/Graduate Professional Schools
List all, completed or not.
Name of Institution:
*
Degree Awarded:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Graduation Date:
*
-
Month
-
Day
Year
Date
Do you have another Institution to enter?
*
Yes
No
Name of Institution:
*
Degree Awarded:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Graduation Date:
*
-
Month
-
Day
Year
Date
Do you have another Institution to enter?
*
Yes
No
Name of Institution:
*
Degree Awarded:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Graduation Date:
*
-
Month
-
Day
Year
Date
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Oklahoma Credentialing Application
Section 5 of 14: Training
Internship/Residency/Fellowship/Preceptorship/Other
List all, completed or not.
Type of Program:
Internship
Residency
Fellowship
Preceptorship
Other
Was program successfully completed?
*
Yes
No
Specialty:
*
Name of Institution:
*
Your Program Director:
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Do you have another program to enter?
*
Yes
No
Type of Program:
*
Internship
Residency
Fellowship
Preceptorship
Other
Was program successfully completed?
*
Yes
No
Specialty:
*
Name of Institution:
*
Your Program Director:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Do you have another program to enter?
*
Yes
No
Type of Program:
*
Internship
Residency
Fellowship
Preceptorship
Other
Was program successfully completed?
*
Yes
No
Specialty:
*
Name of Institution:
*
Your Program Director:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Do you have another program to enter?
*
Yes
No
Type of Program:
*
Internship
Residency
Fellowship
Preceptorship
Other
Was program successfully completed?
*
Yes
No
Specialty:
*
Name of Institution:
*
Your Program Director:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
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Oklahoma Credentialing Application
Section 6 of 14: Academic Appointments
Do you have academic appointments to enter?
Yes
No
Academic Appointments
List all, past and present
Name of Institution:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Position/Rank:
*
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Do you have another academic appointment to enter?
*
Yes
No
Name of Institution:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Position/Rank:
*
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Do you have another academic appointment to enter?
*
Yes
No
Name of Institution:
*
Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Position/Rank:
*
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
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Oklahoma Credentialing Application
Section 7 of 14: Health Care Affiliations
Health Care Affiliations:
List, in chronological order, all hospital/health system affiliations where you have ever been employed, practiced, associated, or privileged for the purpose of providing patient care. Do not list affiliations that were part of your training (Section 5).
Do you have a hospital/health system affiliation to enter?
*
Yes
No
Name of Facility:
*
Indicate which of these is your “current primary and secondary admitting facility” (where you currently spend the greatest portion of your time):
*
Primary
Secondary
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Staff Category:
*
Reason for Discontinuance:
*
Department or Service:
*
Do you have another hospital/health system affiliation to enter?
*
Yes
No
Name of Facility:
*
Indicate which of these is your “current primary and secondary admitting facility” (where you currently spend the greatest portion of your time):
*
Primary
Secondary
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Staff Category:
*
Reason for Discontinuance:
*
Department or Service:
*
Do you have another hospital/health system affiliation to enter?
*
Yes
No
Name of Facility:
*
Indicate which of these is your “current primary and secondary admitting facility” (where you currently spend the greatest portion of your time):
*
Primary
Secondary
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Staff Category:
*
Reason for Discontinuance:
*
Department or Service:
*
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Oklahoma Credentialing Application
Section 8 of 14: Other Professional Work History
Other Professional Work History
List, chronologically, all professional work history (i.e. clinics, partnerships, solo/group practices, employment). Include secondary agencies or clinics such as public health and family planning where you perform duties. Account for all time gaps of thirty (30) days or more.
Name of Facility:
*
Nature of Affiliation:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Reason for Discontinuance:
*
Do you have more work history to enter?
*
Yes
No
Name of Facility:
*
Nature of Affiliation:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Reason for Discontinuance:
*
Do you have more work history to enter?
*
Yes
No
Name of Facility:
*
Nature of Affiliation:
*
Mailing Address:
*
Street Address
Suite Number
City
State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Reason for Discontinuance:
*
Please upload your CV:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Did you serve in the US Military/Public Health Service?
*
Yes
No
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Location:
*
Branch of Service:
*
Do you have another US Military/Public Health Service to enter?
*
Yes
No
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Location:
*
Branch of Service:
*
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Oklahoma Credentialing Application
Section 9 of 14: Professional Licenses
Professional Licenses:
List all pending, current, and past professional licenses, registrations, and certifications to practice in your field. Include states where you have ever applied to practice. Examples of “type” of license are MD, DO, DDS, PA, DC, CRNA, MSW, etc.
State: (This first entry must be your Oklahoma License)
*
Please Select
Oklahoma
Type:
*
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have another license to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Type:
*
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have another license to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Type:
*
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have another license to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Type:
*
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have a USMLE/ECFMG Number to enter?
*
Yes
No
USMLE/ECFMG Number:
*
Certification Date:
*
-
Month
-
Day
Year
Date
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Oklahoma Credentialing Application
Section 10 of 14: Certifications and Registrations
Certifications and Registrations:
List all other current certifications and registrations. (DEA=Federal Drug Enforcement Administration; BNDD=the Oklahoma CDS; CDS=Controlled Dangerous Substances)
Do you have DEA certification to to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have another DEA certification to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have a BNND certification to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Do you have a CDS certification to enter?
*
Yes
No
State:
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Number:
*
Original Date of Issue:
*
-
Month
-
Day
Year
Date
Expiration Date:
*
-
Month
-
Day
Year
Date
Are you board certified?
*
Yes
No
Name of Board:
*
Date Initially Certified:
*
-
Month
-
Day
Year
Date
Date Most Recently Recertified:
*
-
Month
-
Day
Year
Date
Date Certification Expires:
*
-
Month
-
Day
Year
Date
Have you ever been examined by any specialty board but failed to pass?
*
Yes
No
You have answered yes above, please upload a word document explaining details.
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Subspecialty Certification and Added Qualifications:
Do you have a Subspecialty or Added Qualification to enter?
*
Yes
No
Subspecialty or Added Qualification:
*
Name of Board:
*
Date Initially Certified:
*
-
Month
-
Day
Year
Date
Date Most Recently Recertified:
*
-
Month
-
Day
Year
Date
Date Certification Expires:
*
-
Month
-
Day
Year
Date
Do you have another Subspecialty or Added Qualification to enter?
*
Yes
No
Subspecialty or Added Qualification:
*
Name of Board:
*
Date Initially Certified:
*
-
Month
-
Day
Year
Date
Date Most Recently Recertified:
*
-
Month
-
Day
Year
Date
Date Certification Expires:
*
-
Month
-
Day
Year
Date
Board Qualifications
If you are not certified, are you qualified to sit for the exam in a primary or subspecialty board or added qualification?
*
Yes
No
Are you planning to take the exam?
*
Yes
No
Are you scheduled to take the exam?
*
Yes
No
Please upload confirmation letter:
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Oral Date Scheduled:
*
-
Month
-
Day
Year
Date
Written Date Scheduled:
*
-
Month
-
Day
Year
Date
Other Date Scheduled:
*
-
Month
-
Day
Year
Date
Subspecialty or Added Qualification:
*
Name of Board:
*
Date Qualified:
*
-
Month
-
Day
Year
Date
Date Qualification Expires:
*
-
Month
-
Day
Year
Date
Classifications:
Are you certified in CPR?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Basic Life Support (BLS)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Advanced Cardiac Life Support (ACLS)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Health Care Provider (CoreC)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Advanced Trauma Life Support (ATLS)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Neonatal Advanced Life Support (NALS)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Pediatric Advanced Life Support (PALS)?
*
Yes
No
Expires:
*
-
Month
-
Day
Year
Date
Are you certified Other?
*
Yes
No
Other
Expires:
*
-
Month
-
Day
Year
Date
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Oklahoma Credentialing Application
Section 11 of 14: Office Information
Primary Office:
Group Name:
Name as it Appears on your W-9:
*
Business Owned By:
*
Type of Practice:
*
Solo
Partnership
Single-Specialty Group
Multi-Specialty Group
Other
Office Manager:
*
Nurse Coordinator:
Group Medicare Number:
Group Medicaid Number:
IRS TAX ID Number::
*
Does this office have lab service?
*
Yes
No
Reference Lab?
*
Yes
No
On Site Lab?
*
Yes
No
CLIA (Clinical Laboratory Improvement Amendments) ID Number:
CLIA (Clinical Laboratory Improvement Amendments) Waiver Number:
Does your office have the following:
Radiology:
*
Yes
No
EKG:
*
Yes
No
Audiology:
*
Yes
No
Treadmill:
*
Yes
No
Sigmoidoscopy:
*
Yes
No
Wheelchair/handicapped access:
*
Yes
No
Other services for the disabled:
*
Yes
No
Please list other services for the disabled:
*
Do you have any other services that were not listed above?
*
Yes
No
Please list other services:
*
Does this office meet all state and local fire, safety and sanitation requirements?
*
Yes
No
Do you provide 24-hour, seven day a week coverage?
*
Yes
No
List all independent licensed non-physicians working in this office:
Name:
Provider Type:
License Number:
Do you have another name to list?
Yes
No
Name:
Provider Type:
License Number:
Do you have another name to list?
*
Yes
No
Name:
Provider Type:
License Number:
Fluent Languages:
You:
Your Staff:
Other Resources:
Office Hours:
Monday From:
Monday To:
Tuesday From:
Tuesday To:
Wednesday From:
Wednesday To:
Thursday From:
Thursday To:
Friday From:
Friday To:
Saturday From:
Saturday To:
Sunday From:
Sunday To:
Do you have physicians covering your practice in your absence? Note: These practitioners must be affiliated with the organization to which you are applying.
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you or your business own, operate, manage or participate in any medical enterprise or business?
*
Yes
No
Please upload a word document explaining:
*
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Do you have a secondary office to enter?
*
Yes
No
Secondary Office:
Group Name:
Name as it Appears on your W-9:
*
Business Owned By:
*
Type of Practice:
*
Solo
Partnership
Single-Specialty Group
Multi-Specialty Group
Other
Office Manager:
*
Nurse Coordinator:
Group Medicare Number:
Group Medicaid Number:
IRS TAX ID Number::
*
Does this office have lab service?
*
Yes
No
Reference Lab?
*
Yes
No
On Site Lab?
*
Yes
No
CLIA (Clinical Laboratory Improvement Amendments) ID Number:
CLIA (Clinical Laboratory Improvement Amendments) Waiver Number:
Does your office have the following:
Radiology:
*
Yes
No
EKG:
*
Yes
No
Audiology:
*
Yes
No
Treadmill:
*
Yes
No
Sigmoidoscopy:
*
Yes
No
Wheelchair/handicapped access:
*
Yes
No
Other services for the disabled:
*
Yes
No
Please list other services for the disabled:
*
Do you have any other services that were not listed above?
*
Yes
No
Please list other services:
*
Does this office meet all state and local fire, safety and sanitation requirements?
*
Yes
No
Do you provide 24-hour, seven day a week coverage?
*
Yes
No
List all independent licensed non-physicians working in this office:
Name:
Provider Type:
License Number:
Do you have another name to list?
Yes
No
Name:
Provider Type:
License Number:
Do you have another name to list?
*
Yes
No
Name:
Provider Type:
License Number:
Fluent Languages:
You:
Your Staff:
Other Resources:
Office Hours:
Monday From:
Monday To:
Tuesday From:
Tuesday To:
Wednesday From:
Wednesday To:
Thursday From:
Thursday To:
Friday From:
Friday To:
Saturday From:
Saturday To:
Sunday From:
Sunday To:
Do you have physicians covering your practice in your absence? Note: These practitioners must be affiliated with the organization to which you are applying.
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you have another physicians covering your practice in your absence to enter?
*
Yes
No
Name:
*
Specialty:
*
Phone Number:
*
Please enter a valid phone number.
Do you or your business own, operate, manage or participate in any medical enterprise or business?
*
Yes
No
Please upload a word document explaining:
*
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Oklahoma Credentialing Application
Section 12 of 14: Copies of Required Documents
Oklahoma Bureau of Narcotics and Dangerous Drugs Registration (BNDD):
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Emergency Care Training Certificates (CPR, etc., if certified):
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Photo Identification:
*
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Oklahoma Credentialing Application
Section 13 of 14: Attestation
Attestation:
NOTE: If “YES” is checked (except if marked *), please explain fully on a separate sheet. Documentation is required if you have malpractice claims pending or settled in the past five (5) years (include any settlements/adjudication’s, original complaint and final disposition). Your signed statement regarding the alleged incident will suffice for pending cases.
Do you currently have any physical, mental, or emotional condition which may impair your ability to render the professional services which are the subject of this application?
Yes
No
Do you currently use illegal drugs or abuse drugs or alcohol?
Yes
No
Do you currently have malpractice insurance coverage?
Yes
No
Has your professional liability insurance coverage ever been denied, canceled, or non-renewed or initially refused upon application?
Yes
No
Has your medical or professional license in any state ever been revoked, suspended, placed onprobation, conditional status, or limited?
Yes
No
Have you ever voluntarily surrendered your license?
Yes
No
Are formal charges pending against you at this time?
Yes
No
Has your DEA Registration Certificate ever been suspended, revoked, subjected to probation, placed on conditional status, or limited?
Yes
No
Do you currently have admitting privileges at any hospital or healthcare facility?
Yes
No
Are all of your admitting privileges in good standing?
Yes
No
Have you ever surrendered your clinical privileges upon threat of censure, restriction, suspension or revocation of such privileges?
Yes
No
Has any hospital ever dismissed you from its staff?
Yes
No
Has any hospital ever revoked, suspended, or limited your privileges?
Yes
No
Has any hospital initiated either type of aforementioned action by formal notice to you?
Yes
No
Has any hospital refused or denied you privileges?
Yes
No
Have you ever voluntarily surrendered your hospital privileges?
Yes
No
Has your membership in any professional society or association ever beencanceled, revoked, or censured?
Yes
No
Have you ever been fined, had an arrangement suspended, been expelled from participation or had criminal charges brought against you by Medicare or Medicaid?
Yes
No
Have you ever been convicted of a felony or involved in charges relating to moral or ethical turpitude?
Yes
No
Have you ever been named as a defendant in any criminal proceeding?
Yes
No
Have you ever been the subject of disciplinary proceedings by any professional association or organization (i.e., state licensing board; county; state or national professional society hospital medical or clinical staff)?
Yes
No
Has any malpractice action against you been brought or settled in the last 5 yearsor has there been any unfavorable judgment(s) against you in a malpractice action?
Yes
No
To your knowledge, is any malpractice action against you currently pending?
Yes
No
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