1000 Lafayette Blvd Suite 1100, Bridgeport CT 06604

Provider Credentialing Application

This Secure Form: This secure form is used to gather information about you so that DBN can provide credentialing services to your facility. This form requires personal information, education and training information, licensure and other professional information in detail. Once submitted, you’ll receive a confirmation page of completion. It is important that you either e-mail, fax, or upload all the required supporting documents to complete your application with DBN. When your profile is complete and you have submitted all supporting documents, you will receive notification of profile completion by your credentialing specialist at DBN. Please note: If an item is listed on your CV, then you can skip that data entry element. But be aware that we need complete dates, not just year, for education, training, and certifications.

New Client Entity Form

Practice Name*

Person Completing This Form*

Contact Phone*

Contact Email*

Practitioner Name

Practitioner Email

NPI

NPI login information

NPI login information: (needed to file your Medicare application)

NPPES Username

NPPES Password

DOB

Gender

Yes

Social Security #

Do you have a complete CAQH Profile*

Yes

I Don't Know

Primary Office Location

Primary Office Location

Primary Office Street

Primary Office City, ST Zip

Primary Office Phone

Personal Information

Personal Information

Home Address

City, ST Zip

Phone

Marital Status

City of Birth

State of Birth

Country of Birth

Active, Discharged, Retired Military

Yes

Education & Training

Education & Training WE MUST HAVE MM/YYYY FOR EACH EDUATION & TRAINING ENTRY

All Education & Training is shown on CV

Yes

All entries on CV shows MM/YYYY start and end dates?

Yes

Do you want to list any Professional Associations?

Yes

Professional Associations

Professional Associations

Languages

Board / Specialty

Board / Specialty

PCP or Specialist

PCP

Specialist

Primary Specialty

Board Certified (Primary Specialty)

Yes

2nd Specialty?

Yes

Notes about Board/Specialty section, such as additional specialties, information about expiration, etc

Hospital Affiliations

Hospital Affiliations

Provide detailed items that are not contained on your CV. Complete dates and addresses are required, so if the information is not on your CV, then complete the details for each item below. Again, DBN cannot begin your credentialing process without these details.

Are Complete Affiliation details including start/end date on your CV?

Yes

Then please complete the information for each present and past hospital affiliation

Then please complete the information for each present and past hospital affiliation

Professional Licensure Information

Professional Licensure Information

License Type

License Number

Issuing Board

Issue State

Issue Date

Expiration Date

Restrictions

Status

License Type

License Number

Issuing Board

Issue State

Issue Date

Expiration Date

Restrictions

Status

ECFMG Number

Date Issued

DEA Number

Expiration Date

Status

CDS Number (state controlled dangerous substance certificate)

State

Expiration Date

Status

Special Certifications (CPR, BLS, ACLS, etc)

Special Certifications (CPR, BLS, ACLS, etc)

Certified In

Start Date

End Date

Certified By

Certified In

Certification Number

Start Date

End Date

Certified By

Notes of other certifications

Medicare ID

Medicaid ID

Professional Liability Insurance

Professional Liability Insurance

Provide insurance history for the last 10 years, or since you began practice if practicing less than 10 years. Provide information on any non-current policies for which you are not sending a copy of your Certificate of Insurance.

Current Policy Number

Carrier

Coverage From

Coverage To

Claims Made and Tail Coverage

Claims Made

Tail Coverage

Single Limits

Aggregate Limits

Exclusions

Status

Do you have other coverage to report?

Yes

Professional Experience

Professional Experience

We must have a minimum of 7 years work history.

We must have a minimum of 7 years work history.

Is your complete work history shown on your CV

Yes

Professional Experience

Professional Experience

We must have 3 references with complete contact information.

We must have 3 references with complete contact information.

Reference #1

Reference #1

Title

Full Name

Suffix

Professional Suffix

Street Address

City, ST Zip

Country

Phone

Fax

Dates of Association

Dates of Association

From

Reference #2

Reference #2

Title

Full Name

Suffix

Professional Suffix

Street Address

City, ST Zip

Country

Phone

Fax

Dates of Association

Dates of Association

From

Reference #3

Reference #3

Title

Full Name

Suffix

Professional Suffix

Street Address

City, ST Zip

Country

Phone

Fax

Dates of Association

Dates of Association

From

ATTESTATION QUESTIONS - All are required Licensure

ATTESTATION QUESTIONS - All are required Licensure

1) Has your license to practice in your profession ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?

Yes

2) Have you ever received a reprimand or been fined by any state licensing board?

Hospital Privileges and Other Affiliations

Hospital Privileges and Other Affiliations

3) Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

Yes

4) Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?

Yes

5) Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?

Yes

Education, Training and Board Certification

Education, Training and Board Certification

6) Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?

Yes

7) Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?

Yes

8) Have any of your board certifications or eligibility ever been revoked?

Yes

9) Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?

Yes

DEA or CDS

DEA or CDS

10) Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished?

Yes

Medicare, Medicaid or other Governmental Program Participation

Medicare, Medicaid or other Governmental Program Participation

11) Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?

Yes

Other Sanctions or Investigations

Other Sanctions or Investigations

12) Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?

Yes

13) To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?

Yes

14) Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?

Yes

15) Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency?

Yes

Malpractice Claims History

Malpractice Claims History

16) Have you had any malpractice actions within the past 10 years (pending, settled, arbitrated, mediated, or litigated)? If yes, provide information for each case.

Yes

17) Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?

Yes

18) Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based on your individual liability history?

Yes

Criminal

Criminal

19) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional?

Yes

20) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense?

Yes

21) Have you ever been court-martialed for actions related to your duties as a medical professional?

Yes

Ability to Perform Job

Ability to Perform Job

22) Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Feral law." The term does include, however, the unlawful use of prescription controlled substances.

Yes

23) Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?

Yes

24) Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?

Yes

25) Are you unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?

Yes

Free Text

You may upload required document copies at this time to help speed up your application process. these documents are needed to complete your credentialing file so that we have all information necessary to provide you with enrollment services. Not all documents will apply to every practitioner.

Required Documents Include: 1) Practitioner License(s)2) Malpractice Insurance (Certificate of Insurance)3) DEA (federal) and state CDS certificates4) Board Certification(s)5) Diploma - copy of highest level of education (M.D., D.O, MSN, etc)6) Certificates of completion for all medical training (internship, residency, fellowship)7) Current copy of CV (showing current employer and MM/YYYY on all education and experience)8) IRS Form W-99) Current driver's license

Other documents that may be applicable: 1) ECFMG Certificate (if educated in foreign country)2) Passport or other citizenship documents (if born in another country)

Upload your Required Documents

Reach Us

1000 Lafayette Blvd Suite 1100, Bridgeport CT 06604

(888) 220-7011

Business Hours

Mon - Sat : 8am to 6pm
Sun : Closed