PHYSICIAN INITIAL CREDENTIALING APPLICATION

Introduction

Telehealth is an emerging field and is another area in which the credentialing standards for physicians will evolve. As a leader in the telehealth field, our network physicians must meet the highest standards relevant to this industry. The goal of this guide is to familiarize our network physicians with the collecting and organizing of the information and documents required for our credentialing process.

This guide refers to specific documentation for credentialing. We strongly suggest that you use a secure cloud storage medium or a USB storage drive for the documents. We recommend using the most commonly saved file formats - .pdf or .tif.

Most of the required items may already be familiar to you.

What is Credentialing?

Credentialing is the process of verifying the qualifications, background, and legitimacy of physicians and allied health providers. It is an objective evaluation of a provider's current licensure, training and/or experience, competence, and ability to provide particular services and/or perform particular procedures.

How Does The Credentialing Process Work?

The Credentialing Process at e-Telmed begins with a comprehensive application. Your file is reviewed, cross-checked, and verified (i.e. Background Checks, NPDB, FSMB, OIG, EPLS, State License & DEA) for accuracy by a Credentialing Processor.

Our processors are tasked with collecting supporting documents from providers, cross-checking the information, verifying the authenticity of what is provided, and preparing the file for the credentials committee.

Our Credentialing Committee is composed of three to five executives who represent our organization. The committee meets biweekly to review and discuss all provider files prepared by the Credentialing Processors. The Committee will either approve or decline a provider based on the file. Applicants should remember that virtually everything represented in the documentation will be verified.

What documents do we need?

As the field of telemedicine grows, the requirements for credentialing will change. It is important for telemedicine physicians to understand that while something might not have been required in the past, it is now being required or soon will be. We encourage all physicians to scan copies of their supporting documentation into image files that can be kept and transmitted electronically. This will assist in the organization of required documents.

Application:

We will provide an application that must be completed in its entirety. Keep copies of the applications that you have prepared, as they are good to refer to from time to time should a question arise.

When filling out our application, be prepared with all the important data of your practice history. You should list all hospitals where you have had privileges, all State Licenses you have held (whether currently active or not), your Board Certification dates, and the details of any malpractice claims or disciplinary actions. If something is left out and subsequently discovered as the credentialing processors do their research, it is a red flag that could result in a denial.

CV:

The primary thing to remember about the CV that you submit as part of the credentialing process is that it must show the chronological progression of your career with dates being in month/year format.

Education Diplomas & Certificates:

To complete the application, you will need copies of your Undergraduate, Medical School, Residency, and Fellowship diplomas and/or certificates. If your Medical School Diploma is in a language other than English, a certified translation will be necessary.

If you are still in your training program, you may need a letter of good standing from your program director.

Board Certificates:

You will need copies of your Board Certification Certificates. The certificate you present should clearly state the expiration date thereof (if your certification is a lifetime certification, it may not have expiration).

ECFMG or Fifth Pathway:

If you studied at a non-U.S. accredited medical school, you will need to provide your ECFMG or Fifth Pathway certificate.

Licenses and Controlled Substance Registrations:

You will need current copies of all state licenses you hold. You will also need copies of all Federal DEA registrations you hold as well as any state-issued controlled substance registrations. Each of these documents should have their respective expiration date indicated. – N/A for Telehealth Credentialing.

Life Support Cards:

You will need to provide copies of all current BLS, ACLS, ATLS, NRP, APLS, and PALS Certificate cards that you hold. These should all indicate the expiration date. – N/A.

CME Certificates:

You will need copies of your Continuing Medical Education Certificates for the past 2 years.

Certificates of Professional Liability Insurance:

You will need copies of your certificates of insurance (also called a "binder") for your professional liability coverage (malpractice coverage) for the past 5 years. Your practice manager should have these and your hospital's medical staff office may also be able to provide you with a copy (hospitals require it in their files).

Driver's License:

You will need a notarized copy of your Driver's License or other state-issued identification with your picture on it. Make a color copy of your Driver's License and then have a notary attest and sign that it is you. Most banks offer notary services free of charge to their customers.

Passport Size Photos:

We require a recent passport-size photo or uploaded equivalent when you send in the application. If applicable be sure to write your name on the back of each.

PPD & MMR:

We do not require PPD & MMR information.

Case Logs:

We do not require case logs.

Please return all of the above-requested documents via email to Info@etelmed.com

Photo/identification required: Photo

The information requested in this application is necessary to complete the credentialing process. Failure to provide the requested information may result in delay and approval of your credentialing file. Please note and skip the areas on the Checklist that are marked as N/A.

• Type or print your responses.
• This application is invalid if modified.
• All questions must be answered fully and truthfully. If an answer requires an explanation, please provide it on the appropriate form provided. Make additional copies of any of the attached forms if more than one is needed and provide your name on all attachments. You may also submit narratives and/or other documentation to support your answer.
• Note that months/years are required for the application's education and work history sections. All periods during your clinical career must be accounted for. Gaps of greater than sixty (60) days require an explanation. Please use the explanation form to provide this information.
• Please do not leave any blanks. If a particular section does not apply to you, write "n/a" in that section.
• A response of "See CV" is not acceptable unless you also submit a current CV containing all of the requested information.
• Please sign and provide a current date on the attestation and release pages of the application, the provider agreement, and any other forms completed.
• After the application has been completed in its entirety, save a copy of the application for future reference. Attach all documentation shown on the next page to your application before e-mailing or sending by postal mail.

Please provide name and address of someone who will always know your forwarding address:

List all current and past board certifications.

Please answer the following questions. Attach explanation form(s) if necessary.

Clinical Certification

Federal Provider Information

Foreign Graduates

Licensing Exams Taken

Please enter the information below for all states in which you have held a medical license.

Please list in reverse chronological order with current affiliation(s) first. Include affiliations for the last 5 years. Do not list residencies, internships or fellowships. Attach additional sheet if needed.

Please list six physician references that are able to comment upon your current (within the past year) clinical and professional capabilities.

Please list all your practice locations and employment affiliations to cover at least the past 5 years of clinical practice. Beginning and ending month and year are required for each listing. Please provide a separate explanation of work gaps over 30 days in duration. If you desire eTelmed not to contact these facilities, please check the appropriate box and attach a letter of explanation. You may attach an additional sheet if all required work history information will not fit in this section.

If your answer to any of the following questions is "Yes", please provide a full explanation on the attached Credentialing Application Explanation Form and include any additional documentation if necessary.

Have any of the following ever been, or are currently in the process of, being: denied, revoked, suspended, reduced, limited, placed on probation, not renewed, surrendered or voluntarily relinquished? If the answer is "Yes" to any item please provide an explanation as outlined above.

The following information is necessary to complete the credentialing verification process and will be kept confidential. Please print or type answers for any malpractice claims reported to your malpractice insurance carrier, opened, closed, dismissed, settled or paid. Please complete a separate form for each claim. One case per sheet only (photocopy first if additional sheets needed).

2. What is/was your status:

Current Status: (please check one)

This Professional Liability Claims Information Form is required on all claims/lawsuits. Clinical details are required for all suits, regardless of status or settlement amount.

I certify that the information contained in this form is correct and complete to the best of my knowledge.

If your answer to either of the above questions is "Yes" please provide the following information on each claim and provide a brief clinical summary of each case on the attached Professional Liability Claims Information Form.

Please list your current malpractice insurance carrier and the associated information for the last 10 years. If you currently do not carry any malpractice insurance, please list the last malpractice insurance carrier which provided coverage for you. In addition, please list any malpractice insurance carrier who has been associated with any malpractice claim, suit or settlement listed below.

Please make as many copies of this page as needed to fully respond to each question for which you answered "yes". Provide your name on each page if additional sheets are used. Identify the Section of the application that you are providing an explanation for.

Please provide CME activity completed within the last 2 years. This summary form may be submitted in lieu of sending copies of your CME certificate(s) for internal credentialing; however, some facilities may require actual copies for privileging. Please make as many copies as needed.

I (WE) hereby authorize LocumTenens.com, herein after called Individual, to initiate credit entries and/or correction entries to our Checking Savings account (select one) indicated below at the depository named below, herein called DEPOSITORY, to credit the same such account. I acknowledge that the origination of the ACH transactions to my account must comply with the provisions of the U.S. law.

This authorization is to remain in full force until the Individual has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Individual and DEPOSITORY reasonable opportunity to act upon it.

Please fax completed copy to: Info@etelmed.com

After we receive your completed form, a prenote will be sent to your bank. Afterwards, we must wait six business days to allow time for your bank to validate your account information and get back to us if problems are encountered. Please keep this time frame in mind when anticipating your first direct deposit. If you have any questions concerning whether or not your check will be paper vs. electronic, please call us to verify.