CONFIDENTIAL/PROPRIETARY California Participating Physician Reapplication This application is submitted to herein this Healthcare Organization1 I. Addenda Submitting Please check the following Addendum A - Health Plan and IPA/Medical Group Addendum B - Professional Liability Action Explanation endorsed by American Medical Group Association - 703/838-0033 x325 California Association of Health Plans - 916/552-2910 California Healthcare Association - 916/552-7574 California Medical Association -...
california participating physician reapplication

Get the free california participating physician reapplication form

Fill form: Try Risk Free
  • Get Form
  • eSign
  • Fax
  • Email
  • Add Annotation
  • Share

Who needs a physician reapplication?

This an essential document in the regular recredentialing process for practicing physicians in the State of California. They must fill it out upon request from the medical institution or another healthcare organization in order to prove professional competence and qualify for renewing a contract with this entity.

What is a physician reapplication for?

Recredentialing is usually held every three years, or when the initial contract between a physician and a healthcare organization is about to expire. Upon the due date, employer’s representative sends a request to the physician for filing this reapplication alongside several addenda regarding physician’s level of competence.

Is it accompanied by other forms?

There are 4 addenda to this application: State Medical License, DEA Certificate, Board Certification (if applicable) within last three years, Face Sheet of Professional Liability Certification. All copies must be up-to-date.

When is physician reapplication due?

This reapplication must be filed before the current contract between a physician and a healthcare institution expires. Physicians should not submit this reapplication, if they would not to change their job.

How do I fill out a physician reapplication?

Physicians are to furnish this application with identifying information, service information, residencies and fellowships, board certification and other certifications within the last three years, medical licensure/registration, other state medical licenses, professional liability, current hospital and other institutional affiliations. Also there must be work history for the last three years. Another thing is a questionnaire with checkboxes called “Attestation questions”. Physicians must explain their answers in the checkboxes on a separate sheet of paper. In the end they must sign the Information Release Acknowledgements.

Where do I send it?

Reapplication must be submitted to the HR department of the healthcare organization hiring the physician.

Video instructions and help with filling out and completing california participating physician reapplication