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Minnesota Uniform Credentialing Application Template

The Minnesota Uniform Credentialing Application serves as a standardized form designed to streamline the reappointment process for physicians, dentists, and allied health professionals in Minnesota. By gathering detailed information about an applicant's credentials, employment history, education, and more, the form ensures that the reappointment process is thorough, efficient, and consistent across the state. If you are preparing for your reappointment, ensure you have accurately completed each section of the form and click the button below to proceed.

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Table of Contents

In the complex landscape of healthcare credentialing, the Minnesota Uniform Credentialing Application form stands as a crucial tool for physicians, dentists, and allied health professionals navigating the reappointment process. This meticulously designed document serves multiple purposes, providing a streamlined method for professionals to present their qualifications, experiences, and capabilities. Its structure demands detailed information on personal data, credentialing contact information, and a comprehensive historical record of employment, training, and hospital affiliations. Additionally, the form addresses critical aspects such as language fluency, practice locations, scope of practice, and offers spaces for disclosing any potential areas of concern that require further explanation. By requiring all information to be printed in black ink or electronically generated, the form underscores the importance of clarity and legibility. Its emphasis on complete and accurate entries without the use of abbreviations, along with the necessity for legible signatures and specific date formats, ensures that the credentialing process progresses smoothly and efficiently. This stringent approach to gathering a professional’s career and credentialing information reflects the deep commitment to safeguarding patient care standards and underscores the significant role of thorough documentation in the healthcare industry.

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Minnesota Uniform Credentialing Application

Reappointment

Physician/Dentist/Allied Health Professional

Applicant Name (as shown on your state license):

___________________________________________________________________________________________________________

LastFirstMiddleSuffixTitle

CREDENTIALING CONTACT INFORMATION
Name	_________________________________________________________	Phone Number _______________________________
Address	_________________________________________________________	Fax Number _______________________________
	_________________________________________________________	E-mail ______________________________________
	_________________________________________________________

This Box to be Completed by Allied Health Professionals Only

Profession/Title _______________________________________________________

Sponsoring/Collaborative Physician _______________________________________

(Must complete if PA-C or APRN)

Instructions

The reappointment application and attachments should be filled out completely and accurately and must be legible or electronically generated. If more space is needed than provided on the application, please attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. ALL SIGNATURES AND DATES MUST BE CLEARLY LEGIBLE.

Please verify that you have:

Provided complete street address, phone, fax and e-mail addresses wherever indicated, including education/training, past employment, hospital affiliations & references



Designate dates by month, day and year time frames

Answered all of the Disclosure Questions on Pages 11 and 12 and enclosed explanations for affirmative answers

Signed and dated the Attestation Signature and Date statement (Page 13)

Signed and dated the Authorization and Release (Page 14)

All Information Must Be Printed in Black Ink or Electronically Generated

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Practitioner Name:

Last:

First:

Middle:

Practitioner NPI:

Practitioner Race and Ethnicity Information

Race and/or ethnicity (for health plan use only): (The following information is optional and may be used in provider directories to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members.)

Select one or more	American Indian or Alaska Native	Native Hawaiian or Other Pacific Islander	Hispanic or Latino
Select one or more	American Indian or Alaska Native	Native Hawaiian or Other Pacific Islander	Hispanic or Latino
categories:	Asian	White	Prefer not to say
	Black or African American	Other:

Check here if you do not wish for your race and/or ethnicity to be displayed in provider directories:

If provided on the credentialing application, the health plan may utilize race and/or ethnicity information in provider directories or in internal resources to help members make informed choices and/or to help ensure that our network of providers is adequate to meet the needs of our members. Providing race and/or ethnicity information on the credentialing application is entirely optional and refusal to provide this information will NOT subject you to adverse treatment. This information will not be considered in making any decisions regarding your credentialing.

Personal Data

Name (as shown on your state license):

__________________________________________________________________________________________________________________

Last	First		Middle	Suffix	Title
All Former Aliases: _____________________________________ Spouse Name (optional): _____________________________
Date of Birth: ___________________________________		Gender:	 Male	Female
Social Security Number: ___________________________________ NPl: _________________________________________
Current Home Address:
______________________________________________________________________________________________
Street			City/State/Country	Zip Code
Preferred Mailing Address:  Office	 Home	Practitioner’s Preferred E-mail address: ___________________________________

Cell Phone Number: ___________________________________ Home Phone Number: ___________________________________________

Do you speak a language other than English with sufficient fluency to treat patients who speak only that language?  Yes  No

If yes, specify languages: _____________________________________________________________________________________________

Primary or Pending Practice Location

Primary Practice Location/Clinic Name: __________________________________________________________________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Office Phone Number: ______________________________________ Fax Number: ______________________________________________

Federal Tax ID Number: ______________________________________ Type II NPI: _____________________________________________

E-mail Address: ____________________________________________________________________________________________________

Start Date (at this location): ___________________________________________________________

Practicing as:  Primary Care	 Specialist	 Urgent Care	 Locum Tenens		 Moonlighting Resident	 Hospitalist
 Hospital Based only	 Teaching/Research only		 Other (specify) _______________________________________
Accepting new patients?  Yes	 No	Directory Suppress?	 Yes	 No

Primary Specialty in which care will be provided: __________________________________________________________________________

Sub Specialty (ies) in which care will be provided: _________________________________________________________________________

Provide a narrative description of your clinical practice including special interests (if additional space is required, attach a separate sheet):

_________________________________________________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 2 of 17

Additional Practice Location(s) – Since Last Reappointment Applicant Name:

Other Practice Name: ____________________________________________________ Phone Number: _____________________________

Address: __________________________________________________________________________________________________________

StreetCity/State/CountryZip Code

E-mail Address: __________________________________________ Fax Number: _______________________________________________

Federal Tax ID Number (if different from primary): _____________________________ Type II NPI: __________________________________

Credentialing Contact: ________________________________________________________ Phone Number: __________________________

Start Date (at this location): ___________________________________________________________

Practicing as:  Primary Care	 Specialist	 Urgent Care	 Locum Tenens		 Moonlighting Resident	 Hospitalist
 Hospital Based only	 Teaching/Research only		 Other (specify) ________________________________________
Accepting new patients?  Yes	 No	Directory Suppress?	 Yes	 No

Primary Specialty in which care will be provided: ___________________________________________________________________________

Sub Specialty (ies) in which care will be provided: __________________________________________________________________________

Fellowship/Post-Graduate/Professional Training – Since your last reappointment

(Month, day and year required)
From: _______________		Institution Name: _____________________________________________________________________________
To:	_______________	Type of Program/Specialty: ____________________________________________________________________
		Completed Training:  Yes  No If no, expected completion date: ___________________________________
		If not successfully completed, explain: ____________________________________________________________
		Program Director: ____________________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: ___________________________________ Fax Number: _______________________________
		E-mail address: _____________________________________________________________________________
Professional and Academic/Faculty Affiliations - Since your last reappointment

(Month, day and year required)
From: ______________		Institution Name: _____________________________________________________________________________
To:	_______________	Appointment Held/Position: _____________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code

Phone Number: _____________________________________ Fax Number: _____________________________

E-mail address: _____________________________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 3 of 17

Chronological Employment/Practice History (include Military Service)	Applicant Name:

(Additional space is provided on the Chronological Employment/Practice History Addendum. You may make extra copies of page 16 for additional employments.)

Chronological listing [month/day/year] of employment/practice history since your last reappointment. List all experience, including military service and public health, time out of medical practice in pursuit of other business or professional activities, sabbaticals, parenting, personal travel, personal crisis, etc. LEAVE NO GAPS IN CHRONOCLOGY.

(Month, day and year required)

From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: _______________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?  Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

	Street	City/State/Country	Zip Code
	Phone Number: ______________________________________ Fax Number: ____________________________
	E-mail address: ______________________________________________________________________________
From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: _______________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?  Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

	Street	City/State/Country	Zip Code
	Phone Number: ______________________________________ Fax Number: ____________________________
	E-mail address: _____________________________________________________________________________
From: _______________	Organization Name: __________________________________________________________________________
To: _______________	Title/Position: _______________________________________________________________________________
	Reason for Leaving: __________________________________________________________________________

Employment Contact Name: ____________________________

Clinic Still Open?  Yes  No

If no, attach sheet listing address and phone number of someone who can verify your time there.

Address: ___________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ______________________________________ Fax Number: ____________________________

E-mail address: _____________________________________________________________________________

Check here if you have additional employment history on attached Chronological Employment/Practice History Addendum (page 16)

Time Gaps: Explain gaps/interruptions of greater than three (3) months to practice of medicine/professional practice - since your last reappointment (if additional space is required, you may make extra copies of page 16 for additional time gaps.)

(Month, day and year required)

From: _______________		Explain: ____________________________________________________________________________________
To:	_______________	___________________________________________________________________________________________
From: _______________		Explain: ____________________________________________________________________________________
To:	_______________	___________________________________________________________________________________________

Check here if you have additional time gap information on attached Chronological Employment/Practice History Addendum (page 16)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 4 of 17

Primary Hospital Affiliation	Applicant Name:

(pertinent to Primary or Pending Practice Location listed on page 2)

If no hospital admitting privileges, describe method/coverage for continuity of care. Please provide covering physician’s name, if applicable.

_________________________________________________________________________________________________________________

(Month, day and year required)
From: _______________		Facility Name: _______________________________________________________________________________
To:	_______________	Type/category of privilege/affiliation (active, courtesy, etc.): ___________________________________________
 Application Pending		Department Chairperson: ______________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: _____________________________________ Fax Number: _____________________________
		E-mail address: ______________________________________________________________________________
Admitting Privileges:		 Yes  No (If no, please complete box above)
Other Hospital Affiliations - Since your last reappointment (Additional space is provided on the Hospital Affiliation
Addendum. You may make extra copies of page 17 for additional affiliations.)
(Month, day and year required)
From: _______________		Facility Name: _________________________________________________________________________
To:	______________	Former Facility Name (if applicable): ____________________________________________		Facility Still Open?
				 Yes  No

		Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
 Application Pending		Department Chairperson: ______________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: _____________________________________ Fax Number: _____________________________
		E-mail address: ______________________________________________________________________________
Admitting Privileges:		 Yes  No (If no, please complete box above)
From: _______________		Facility Name: _________________________________________________________________________
To:	______________	Former Facility Name (if applicable): ____________________________________________		Facility Still Open?
				 Yes  No

		Type/category of privilege/affiliation (active, courtesy, etc.): ____________________________________________
 Application Pending		Department Chairperson: ______________________________________________________________________
		Address: ___________________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: _____________________________________ Fax Number: _____________________________
		E-mail address: ______________________________________________________________________________
Admitting Privileges:		 Yes  No (If no, please complete box above)

Check here if you have additional hospital affiliations on attached Hospital Affiliation Addendum (page 17)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 5 of 17

Specialty/Subspecialty Certification	Applicant Name:

(Additional space is provided on the Specialty and Licensure Addendum, page 17. You may make extra copies of page 17 or attach a separate sheet for additional Specialty and Licensure.)

Primary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Specialty: ____________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending 

Secondary Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending 

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending 

Additional Specialty:

Board Name: _______________________________________________________________________________________________________

Board Sub-specialty: _________________________________________________________________________________________________

Certificate Number: _________________________________________ Original Certificate Date: ____________________________________

Expiration Date: ____________________________________________ Certificate Pending 

Check here if you have additional specialty on attached Specialty and Licensure Addendum (page 18)

If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.

_________________________________________________________________________________________________________________

Licensure - List all past, current and pending professional licenses.

(Additional space is provided on the Specialty and Licensure Addendum, page 18. You may make extra copies of page 18 or attach a separate sheet for additional Specialty and Licensure.)

License Type	State	License Number	Date Issued	Expiration Date	License Status
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending
__________	________	_________________	_______________	_______________	 Active  Inactive  Pending

Check here if you have additional licensure on attached Specialty and Licensure Addendum (page 18)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 6 of 17

Drug Enforcement Administration Registration

Applicant Name:

NOTE: Address on DEA certificate must be in state where you will be practicing as applicable to this application.

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules?  Yes  No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules?  Yes  No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules?  Yes  No, please explain: ________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules?  Yes  No, please explain _________________________________________________________

DEA Number: ______________________________________ State: _____________________________ Expiration Date: ________________

Approved for all schedules?  Yes  No, please explain _________________________________________________________

If you do not maintain a DEA certificate, please explain:

Not applicable to practice  DEA certificate pending; date application submitted to DEA: ___________________________________

Other ______________________________________________________________________________________________________

State Controlled Substance Certification/Registration (If applicable - not applicable to MN, WI, ND).

Issued By: ___________________________________ Number: _________________________________ Expiration Date: _______________

Life Support Certification

Do you have any current life support certifications (BLS, ACLS, ATLS, etc.)?	 Yes  No
If Yes: Type of Certification	Expiration Date(s)
___________________________________________________________	_______________
___________________________________________________________	_______________
___________________________________________________________	_______________
___________________________________________________________	_______________

Continuing Education Attestation

Please read the following attestation carefully before signing and dating the statement.

I hereby certify that I have a sufficient number of CE credits to meet the licensure requirements and attest that an appropriate percentage relate to my specialty. I understand that these credits may be audited by an individual facility based on their individual requirements.

All signatures and dates must be clearly legible or signed with a unique electronic identifier.

Signature: __________________________________________________________ Date: _________________________

Name: ______________________________________________________________________________________________

(please print or type)

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 7 of 17

Liability Insurance

Applicant Name:

Insurance Carrier for Primary and Pending Practice Location (You may attach a separate sheet for additional Liability Insurance.)

Enclose a copy of professional liability insurance coverage (e.g., face sheet/verification of self-insurance) for primary practice location to include effective dates, insurance carrier, expiration date, coverage limits, and name of each provider covered. If additional space is required, attach a separate sheet.

Coverage dates:

(Month, day and year required)
Start:	_______________	Current Insurance Carrier Name: ___________________________________________________________
Expire:	_______________	Address: _______________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: ________________________________ Fax Number: ______________________________
		E-mail address: _________________________________________________________________________
 Certificate Pending		Name in which policy issued: ______________________________________________________________
		Policy number: _________________________________________________________________________
		Amount of coverage (per occurrence): _______________________________________________________
		Amount of coverage (per aggregate): ________________________________________________________
Start:	_______________	Insurance Carrier Name: _________________________________________________________________
Expire:	_______________	Address: ______________________________________________________________________________
		Street	City/State/Country	Zip Code
		Phone Number: ________________________________ Fax Number: _____________________________
		E-mail address: _________________________________________________________________________
		Name in which policy issued: ______________________________________________________________
		Policy number: _________________________________________________________________________
		Amount of coverage (per occurrence): _______________________________________________________
		Amount of coverage (per aggregate): ________________________________________________________
Start:	_______________	Insurance Carrier Name: _________________________________________________________________
Expire:	_______________	Address: ______________________________________________________________________________
		Street	City/State/Country	Zip Code

Phone Number: ________________________________ Fax Number: _____________________________

E-mail address: _________________________________________________________________________

Name in which policy issued: ______________________________________________________________

Policy number: _________________________________________________________________________

Amount of coverage (per occurrence): _______________________________________________________

Amount of coverage (per aggregate): ________________________________________________________

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 8 of 17

Professional/Peer References	Applicant Name:

List three (3) professional peers who have personal knowledge of your current (within the past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation of your work. A peer is defined as an individual in the same professional discipline with essentially equal qualifications (MD and DO are considered equivalent; DDS/DMD for DDS/DMD; DPM for DPM; PhD for PhD, etc.) Limit to one (1) current office associate. Do not include your residency director, fellowship director, relatives, or pending partners. At least one reference should be in your specialty (and if possible from the same subspecialty). Provide current and complete addresses. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you.

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Name: _______________________________________________________________ Title: ________________________________________

Facility Name: __________________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

StreetCity/State/CountryZip Code

Phone Number: ________________________________________________ Fax Number: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Immune Status Information for Reappointment – Please provide immunity status by completing the question below.

DATE OF LAST PPD/MANTOUX:

Results:

Signature:

Date:

Reappointment Application – 09/2001; REV 04/2002; 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, 10/2016,4/2022

Page 9 of 17

Get PDF

Form Breakdown

Fact Name	Description
Form Purpose	The Minnesota Uniform Credentialing Application is used for the reappointment of Physicians, Dentists, and Allied Health Professionals.
Application Completeness	Applicants must ensure the application and attachments are filled out completely, accurately, and legibly or generated electronically.
Information Requirement	All requested details such as complete addresses, phone numbers, fax numbers, e-mail addresses, employment histories, hospital affiliations, and references must be provided.
Signatures	All signatures and dates within the application must be clearly legible to be considered valid.
Disclosure Questions	Applicants are required to answer all Disclosure Questions thoroughly and provide explanations for affirmative answers.
Governing Laws	This form operates under Minnesota's healthcare regulations and credentialing standards to ensure that healthcare professionals meet the required qualifications for practice.

Guidelines on Filling in Minnesota Uniform Credentialing Application

Filling out the Minnesota Uniform Credentialing Application form is a straightforward process designed to ensure that medical professionals provide the necessary information for credentialing purposes. The form requests detailed personal, professional, and practice-related information. To successfully complete the application, it's important to follow the instructions carefully, provide accurate and legible information, and avoid abbreviations unless specified. Here are the steps to fill out the form, ensuring all sections are properly addressed.

Begin by entering your Applicant Name as shown on your state license, including Last Name, First Name, Middle Name, Suffix, and Title.
Under CREDENTIALING CONTACT INFORMATION, provide the Name, Phone Number, Fax Number, Address, and E-mail of your credentialing contact.
If you are an Allied Health Professional, fill in the Profession/Title and Sponsoring/Collaborative Physician sections.
Ensure you have checked all the initial verification boxes on the first page, including providing complete addresses and accurately designating dates.
Fill in your Personal Data including all former aliases, spouse name, date of birth, gender, Social Security Number, NPl, current home address, preferred mailing address, preferred email address, and phone numbers. Indicate if you speak any languages other than English.
Detail your Primary or Pending Practice Location information, including clinic name, address, contact information, Federal Tax ID, Type II NPI, start date, practice type, and whether you are accepting new patients.
Add any Additional Practice Location(s) since your last reappointment, replicating the information required for the primary practice location.
Document your Fellowship/Post-Graduate/Professional Training since the last reappointment, including institution names, program types, dates, completion status, and program director contact information.
List Professional and Academic/Faculty Affiliations since your last reappointment with the relevant details on position, institution, and contact information.
Provide a Chronological Employment/Practice History including military service, with no gaps, since your last reappointment. Specify organization names, positions, reasons for leaving, and employment contacts.
Explain any time gaps in your practice history greater than three (3) months on the designated section or the Chronological Employment/Practice History Addendum.
Under Primary Hospital Affiliation, give details about your primary hospital, including admitting privileges and methods for continuity of care, if applicable.
List any Other Hospital Affiliations since your last reappointment, including facility names, types of privileges, and relevant contact information.
Review your answers, sign, and date the Attestation Signature and Date statement and the Authorization and Release section.
Ensure all information is printed in black ink or electronically generated for clarity.

Upon completion, double-check the application for any missing or incorrect information. Remember, providing complete and accurate data is crucial for the credentialing process. Once finalized, submit the application to the designated address or electronic submission portal, if provided, along with any required attachments or additional sheets referenced in your application.

Learn More on Minnesota Uniform Credentialing Application

What is the purpose of the Minnesota Uniform Credentialing Application form?

The Minnesota Uniform Credentialing Application form is designed for physicians, dentists, and allied health professionals who are seeking reappointment at healthcare facilities. Its purpose is to streamline the process of verifying the credentials of healthcare providers, ensuring that they meet the required standards to provide care to patients. By filling out this application accurately and completely, applicants demonstrate their qualifications, training, and experience in their respective fields.

Who needs to complete the Minnesota Uniform Credentialing Application form?

Physicians, dentists, and allied health professionals seeking reappointment within healthcare facilities in Minnesota must complete the form. This includes those who may be practicing as primary care providers, specialists, urgent care providers, or in any other healthcare capacity that requires credential verification for reappointment.

How should the application be filled out?

The application should be filled out completely and legibly, either by hand in black ink or electronically generated. All sections of the form that apply to the applicant must be completed, including personal data, credentialing contact information, employment history, hospital affiliations, and any additional practice locations. If there is not enough space on the form for any response, additional sheets can be attached with references to the relevant question. Abbreviations should be avoided.

What documentation is required along with the application?

Applicants must verify that they have included complete contact information, designation of dates for their education, training, past employment, as well as hospital affiliations and references. Disclosure questions on the form must be answered completely, with explanations provided for any affirmative responses. Lastly, the Attestation Signature and Date statement and the Authorization and Release section must be signed and dated. All documents must be presented in a clear and legible manner.

Is fluency in languages other than English considered in the application process?

Yes, the application includes a section for applicants to indicate if they speak a language other than English with sufficient fluency to treat patients who only speak that language. Applicants are encouraged to specify which languages they speak, as this can be an important aspect of providing comprehensive care to diverse patient populations.

What happens if there are gaps in the employment history?

Applicants must provide a chronological listing of their employment and practice history since their last reappointment, without leaving any gaps. If there are gaps or interruptions greater than three months in the practice of medicine or professional activity, these must be explained in detail. If additional space is required beyond what is provided on the form, applicants may attach extra copies of the applicable page for a thorough explanation.

How are additional practice locations handled in the application process?

For those applicants with multiple practice locations since their last reappointment, each location must be listed separately on the application. Information required includes the practice name, address, phone number, fax number, email address, federal tax ID number, and NPI number, along with the credentialing contact information. The type of practice (e.g., primary care, specialist) at each location, whether new patients are being accepted, and primary and sub-specialties practiced should also be detailed. This ensures a complete record of all locations where the applicant has practiced.

Common mistakes

One common mistake is not providing complete information where required, such as omitting full street addresses, phone, fax, and e-mail addresses in sections pertaining to education/training, past employment, hospital affiliations, and references. This oversight can lead to delays in the credentialing process.
Applicants often fail to designate dates using the month, day, and year format. This inconsistency can lead to confusion and inaccuracies in verifying the applicant's timeline of professional experience.
Another mistake is not answering all of the Disclosure Questions on Pages 10 and 11 of the application form, which are crucial for assessing the applicant's suitability and background. Failing to enclose explanations for affirmative answers where required can raise concerns about transparency and integrity.
Failing to sign and date the Attestation Signature and Date statement on Page 12, as well as the Authorization and Release on Page 13, is a common error. These signatures are vital for the application's validity and the authorization to verify the information provided.
Applicants sometimes use abbreviations instead of writing out full terms, contrary to the instructions. This practice can lead to misunderstandings and errors in understanding the applicant's qualifications and experiences.
Not printing all information in black ink or generating it electronically can result in applications that are hard to read or appear unprofessional, potentially impacting the review process negatively.

Additionally, common issues found in the supplementary sections include:

Leaving chronological gaps in employment history without providing explanations, as required in the section detailing Chronological Employment/Practice History. This omission can lead to questions about the applicant's professional activities during those periods.
Not checking the box to indicate additional employment history or time gaps on the attached Chronological Employment/Practice History Addendum (page 15), which can result in incomplete consideration of the applicant's professional background.
Omitting the narrative description of clinical practice or not providing sufficient detail regarding the scope and nature of the practice, including special interests. This information is crucial for understanding the applicant's professional focus and capabilities.
Incorrectly completing or failing to provide details in the sections related to Hospital Affiliations, especially regarding admitting privileges and the method/coverage for continuity of care for those without hospital admitting privileges.

Documents used along the form

Submitting the Minnesota Uniform Credentialing Application is a significant step for physicians, dentists, and allied health professionals seeking reappointment and credentialing in Minnesota. This comprehensive application requires careful attention to detail and accuracy to ensure a smooth credentialing process. However, the application alone is often not sufficient; additional documentation is typically required to complete the credentialing or reappointment process effectively. Understanding the common types of forms and documents that may accompany the Minnesota Uniform Credentialing Application can help streamline the preparation and submission process.

Copy of Professional License: A current, valid professional license is fundamental. This document serves as proof of the legal right to practice within the state.
Proof of Malpractice Insurance: Documents showing current malpractice insurance coverage demonstrate financial responsibility and risk mitigation.
Board Certification or Eligibility Documentation: For specialties where board certification is applicable, providing proof of certification or eligibility status underlines professional competency.
DEA Certificate: A Drug Enforcement Administration (DEA) certificate is required for professionals authorized to prescribe medication, indicating compliance with federal regulations.
Curriculum Vitae (CV): A detailed CV offers a comprehensive view of the applicant's education, training, experience, and professional accomplishments.
Continuing Medical Education (CME) Credits: Proof of recent CME credits affirms the applicant's commitment to maintaining up-to-date medical knowledge and skills.
Reference Letters: Letters from peers or supervisors can provide qualitative insight into the applicant's clinical abilities, character, and professional demeanor.
Background Check Authorization Form: This form permits the credentialing body to conduct a thorough background investigation, ensuring the applicant meets all ethical and professional standards.

Together with the Minnesota Uniform Credentialing Application, these documents provide a holistic view of an applicant's qualifications, professional standing, and commitment to excellence in healthcare. Careful preparation and organization of these materials can contribute to a more efficient and successful credentialing process, ultimately facilitating the delivery of high-quality patient care.

Similar forms

The Medical Licensure Application is similar in that it also collects comprehensive personal data, educational background, and professional experience, including practice locations. However, a licensure application uniquely emphasizes qualifications for initial grant of permission to practice within a specific jurisdiction, whereas the credentialing form primarily validates current competencies and affiliations for reappointment purposes.
The Professional Resume/CV shares similarities as it outlines an individual's entire employment history, academic credentials, and professional achievements. Both documents serve to present the applicant’s qualifications comprehensively. The credentialing form, though, is more focused on the specifics required for credentialing and reappointment in healthcare settings.
A Job Application Form collects detailed information about an applicant's past employment, education, and references, similar to the credentialing form. Nonetheless, the job application is used across various industries for employment purposes, while the credentialing application specifically addresses the qualifications and background checks needed in the healthcare sector for credentialing purposes.
The Hospital Privileges Application similarly requires detailed information about a healthcare professional's education, training, and current practice information, designed to assess the applicant’s eligibility for admitting patients or performing specific procedures at a hospital. Both applications evaluate the capacity and privileges a healthcare worker is entitled to within medical facilities.
The Medical Insurance Panel Application parallels the credentialing form in its requirement for detailed professional history, credentials, and practice information. It's designed for healthcare professionals seeking to join an insurance company’s panel of approved providers. Both ensure candidates meet certain standards, albeit for different approval processes.
The Fellowship Application overlaps with the credentialing form by requiring extensive details on education, training, and professional background to evaluate the applicant’s suitability for advanced study or practice in a specialized field of healthcare. The credentialing form similarly assesses qualifications but is focused more on verifying credentials for reappointment and agreeing to provider networks or hospital affiliations.

Dos and Don'ts

When filling out the Minnesota Uniform Credentialing Application form, it's crucial to follow a specific set of guidelines to ensure your application is correctly submitted and processed without delays. Here are some essential tips to keep in mind:

Do:

Provide complete contact information. Ensure all sections requesting your address, phone number, fax, and email are filled out comprehensively.
Use black ink or electronic generation for all information. This makes your application legible and formally acceptable.
Detail your chronological employment/practice history accurately. This includes filling out all required dates (month, day, year) without leaving any time gaps.
Answer all disclosure questions thoroughly. If applicable, include detailed explanations for any affirmative answers.
Sign and date the attestation signature and authorization and release statements. Your signature is required to validate the information provided.
Indicate language proficiencies. Specify if you speak any languages other than English to a level that allows you to treat patients who only speak those languages.
Attach additional sheets if needed. If the space provided on the application is insufficient, attach extra pages and clearly reference the question being answered.

Don't:

Use abbreviations. Write out all terms completely to avoid misunderstandings or misinterpretation of your information.
Leave gaps in your employment or practice history. A complete chronological listing is essential for verifying your experience and background.
Forget to list all affiliations and credentials. Including detailed information about your professional and academic background is crucial.
Submit the application without reviewing it for completeness and accuracy. Double-check every section to ensure all information is correct and no required fields are missed.

Misconceptions

Misconceptions about the Minnesota Uniform Credentialing Application are common among healthcare professionals. Here's a look at some of the most frequent misunderstandings:

It's only for new applicants: Many think the application is just for new applicants, while in reality, it is used for both initial credentialing and reappointments, ensuring that practitioners' information is current and accurate.
Abbreviations are acceptable: Despite a common belief, the form explicitly requests not to use abbreviations. Every detail needs to be clear and fully written out to avoid confusion or misinterpretation.
Electronic signatures aren't allowed: Another misconception is that the form must be signed by hand. However, it clearly states that all information, including signatures and dates, can be electronically generated, making the process more flexible and environmentally friendly.
Any ink color can be used: While some might think any ink color is permissible for those filling the form out by hand, the form specifies that all information must be printed in black ink, ensuring consistency and readability.
Fax and email are optional: Though some may overlook or consider providing fax and email addresses as optional, the form requires complete contact information, including fax and email, to ensure reliable communication.
Language proficiency doesn't matter: There's a belief that language skills are irrelevant. However, the application asks if the practitioner speaks a language other than English fluently enough to treat patients, highlighting the importance of linguistic competence in patient care.
Only primary specialty needs to be listed: Some practitioners might think they only need to list their primary specialty. The form, however, allows for the inclusion of sub-specialties, recognizing the comprehensive scope of many professionals' practices.
Time gaps in practice are problematic: There's a misconception that gaps in practice history will negatively impact the application. The form simply requires these gaps to be explained, acknowledging that there are numerous valid reasons for taking time away from practice.
It's only for physicians and dentists: Despite its title, the form is also for allied health professionals. This broad inclusion ensures that a wide range of healthcare providers can be properly credentialed and recognized.

Understanding these misconceptions can simplify the credentialing process, making it easier for healthcare professionals to provide their services without unnecessary bureaucratic hurdles.

Key takeaways

When it comes to ensuring your professional credentials are up-to-date in Minnesota, the Minnesota Uniform Credentialing Application form plays a crucial role. Navigating through this form can be straightforward if you understand the key elements that require your attention. Here are four vital takeaways to keep in mind:

Complete and accurate information is pivotal. Every section of the application needs your full attention to detail. Provide a complete street address, contact information (including phone, fax, and email addresses) for education/training, past employment, hospital affiliations, and references. This comprehensive approach helps avoid any delays or issues in the credentialing process.
Avoid abbreviations and ensure legibility. The application and any attachments should be free of abbreviations and must be either legibly written or electronically generated. This clarity aids in preventing misunderstanding or the need for additional clarification, thereby streamlining your credentialing or recredentialing process.
Signatures and dates are critical. Don’t overlook the simple yet essential step of signing and dating the application. Specifically, the Attestation Signature and Date statement, as well as the Authorization and Release, must be clearly completed. These signatures legally attest to the accuracy of the information provided and authorize the necessary background and credential checks.
Detail your entire professional history, including time gaps. The application requires a comprehensive account of your professional journey, including any employment gaps longer than three months. Being thorough and transparent about your history, including explaining any breaks or transitions, is essential not only for trust but also for compliance with credentialing standards.

Whether you're applying for the first time or going through the reappointment process, keep these takeaways in mind to ensure a smooth experience with the Minnesota Uniform Credentialing Application. This diligence not only reflects your professionalism but also facilitates a quicker path to practicing in your field.

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