→

Official Minnesota Uniform Credentialing Application Form in PDF

The Minnesota Uniform Credentialing Application form is a standardized document used by healthcare professionals to apply for reappointment. This form collects essential information about the applicant's qualifications, practice history, and affiliations to ensure compliance with state regulations. It is crucial to complete this application accurately and submit it promptly to avoid delays in your reappointment process.

To begin filling out the form, please click the button below.

Create Your Form

Official Minnesota Uniform Credentialing Application Form in PDF

Navigation

The Minnesota Uniform Credentialing Application form serves as a vital tool for healthcare professionals seeking reappointment within the state. This comprehensive document is designed to collect essential information about the applicant, including personal details such as name, contact information, and professional history. It encompasses a wide range of sections, from educational background and work experience to hospital affiliations and specialty designations. Applicants must provide accurate and complete information, ensuring that all sections are legible and free from abbreviations. Each part of the form plays a crucial role in the credentialing process, as it verifies qualifications and maintains the integrity of healthcare services. Additionally, the form includes specific instructions for allied health professionals, guiding them through the requirements for collaboration with sponsoring physicians. Throughout the application, the importance of clarity and thoroughness is emphasized, as applicants must sign and date various sections to confirm the accuracy of their submissions. This structured approach not only streamlines the credentialing process but also fosters a commitment to maintaining high standards in patient care.

Form Example

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

➤ Minnesota Uniform Credentialing Application File

Form Specifications

Fact Name	Description
Form Purpose	The Minnesota Uniform Credentialing Application is designed for reappointment of healthcare professionals including physicians, dentists, and allied health professionals.
Governing Law	This application is governed by Minnesota Statutes, Chapter 147, which outlines the licensing and regulation of health professionals in the state.
Contact Information	Applicants must provide detailed contact information, including phone numbers, email addresses, and mailing addresses, to ensure proper communication.
Legibility Requirement	All entries on the form must be printed in black ink or electronically generated to maintain clarity and legibility.
Disclosure Questions	Applicants are required to answer all disclosure questions thoroughly, particularly those found on Pages 10 and 11 of the application.
Signature Requirement	All signatures and dates on the application must be clear and legible to validate the information provided.
Additional Sheets	If more space is needed for any section, applicants should attach additional sheets and reference the corresponding question.
Language Proficiency	Applicants must indicate if they speak a language other than English fluently enough to treat patients who speak that language.
Practice Location	Details about the primary or pending practice location must be included, such as the clinic name and address, along with the start date of practice.
Revisions History	The form has undergone multiple revisions since its original release in September 2001, with the latest revision dated October 2016.

Please rate Official Minnesota Uniform Credentialing Application Form in PDF Form

4.65

Exemplary

20 Votes

Popular PDF Templates

University of Minnesota Urolith - Necessary information on urolith retrieval date, essential for understanding the timeline of formation and intervention.

For parents looking to delegate authority in specific situations, the temporary Power of Attorney for a Child form is a vital tool that ensures all necessary decisions regarding your child's welfare are made appropriately.

Minnesota State Income Tax Forms - Introduces restrictions on acquired NOLs as per Internal Revenue Code section 382(g), ensuring proper application of these losses.