Free Minnesota Uniform Credentialing Application Form in PDF

The Minnesota Uniform Credentialing Application serves as a comprehensive form designed for the reappointment process of physicians, dentists, and allied health professionals in Minnesota. It meticulously collects personal data, credentialing contact information, practice locations, professional training, employment history, and hospital affiliations to ensure a thorough evaluation process. For professionals seeking to expedite their reappointment, completing this form accurately and legibly is a critical step.

To begin the process of filling out your Minnesota Uniform Credentialing Application, click the button below.

Get Form

For healthcare professionals in Minnesota seeking to renew their credentials, the Minnesota Uniform Credentialing Application plays a crucial role in simplifying the process. This comprehensive form, designed for physicians, dentists, and allied health professionals, demands detailed personal data, credentialing contact information, and a vast array of professional details to ensure a thorough vetting process. Applicants must provide everything from basic personal information, such as name and date of birth, to more detailed professional history, including education, training, employment history, and hospital affiliations. The application meticulously guides the applicant through every necessary step, with instructions to use black ink or electronic means for clarity, and emphasizes the importance of complete and legible responses without abbreviation. It also includes sections for addressing gaps in employment, highlighting the continuous pursuit of professionalism in healthcare. By completing this form accurately, healthcare professionals can ensure their credentials are up-to-date, enabling them to continue providing quality care to their patients without administrative hiccup.

Preview - Minnesota Uniform Credentialing Application Form

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

▼ PDF

Document Specs

Fact Name	Description
Application Purpose	The form is used for the reappointment of physicians, dentists, and allied health professionals.
Application Scope	It applies to those listed on a state license, indicating a requirement for state-specific credentials.
Updates Through Time	The form has seen numerous revisions, demonstrating its evolution to meet current standards. Revisions occurred in 09/2001, 04/2002, 04/2004, 01/2006, 07/2006, 01/2007, 08/2011, and the latest in 10/2016.
Detail Requirement	The applicant is required to provide comprehensive information, including direct contact info, affiliations, and a full educational and professional history.
Disclosure Statements	Applicants must answer all disclosure questions thoroughly, attaching explanations for affirmative responses, emphasizing the need for transparency.
Signature Specifications	All signatures and dates on the form must be clearly legible, ensuring accountability and verification of information.
Governing Law	The application reflects Minnesota's specific regulatory environment, although the governing laws are not explicitly detailed in the provided context.

Instructions on Writing Minnesota Uniform Credentialing Application

The Minnesota Uniform Credentialing Application form is an essential document for healthcare professionals seeking reappointment within the state. This step-by-step guide ensures that the application process is completed accurately and efficiently. Filling out the form thoroughly is vital to avoid delays in the credentialing process, ensuring professionals can continue their practice without interruption.

Start by entering your name as it appears on your state license, including last, first, middle names, any suffix, and your professional title at the top of the form.
Under CREDENTIALING CONTACT INFORMATION, provide the name, phone number, address, fax number, and email address of your credentialing contact.
If you are an Allied Health Professional, specify your Profession/Title and your Sponsoring/Collaborative Physician in the designated box.
Ensure all required boxes are checked on the form’s first page, verifying your submission's completeness, including providing full contact information wherever requested, designating correct dates, answering disclosure questions, and signing the attestation and authorization sections.
In the Personal Data section, fill in all requested information, including any former aliases, spouse's name (optional), date of birth, gender, social security number, NPI number, current home address, preferred mailing address, email, and phone numbers. Also, specify if you speak any languages other than English fluently enough to treat patients who only speak those languages.
For Primary or Pending Practice Location, detail your primary practice clinic’s name, address, contact info, tax ID, and NPI number. Also, mention your start date, the nature of your practice at this location, and if you are accepting new patients.
Fill out Additional Practice Location(s) – Since Last Reappointment if applicable, including details such as other practice names, addresses, contact info, and the nature of each practice.
In the Fellowship/Post-Graduate/Professional Training section, specify any relevant training since your last reappointment, including institution names, program types, and dates.
The section on Professional and Academic/Faculty Affiliations requires information on your positions held, including institution names, appointment, address, and contact information.
Complete the Chronological Employment/Practice History section by listing all employment and practice history since your last reappointment, including organization names, titles/positions, reasons for leaving, and contact information for verification.
Explain any time gaps greater than three months in the practice of medicine/professional practice since your last reappointment in the designated area.
For the Primary Hospital Affiliation section, list your main hospital affiliation pertinent to your primary or pending practice location mentioned earlier, including facility name, type of privilege, and contact details.
Fill out the Other Hospital Affiliations section with additional hospital affiliations since your last reappointment, following the same format as the primary affiliation section.
Ensure all signatures and dates are clearly legible and that the attestation and authorization sections on the last pages are signed and dated.
Before submission, double-check that all information is printed in black ink or electronically generated, and ensure no sections or necessary attachments are overlooked.

After completing the form accurately, review all sections and attachments to ensure that no essential details have been missed. Submitting a complete and correctly filled application is crucial for the timely processing of your reappointment. This guide aims to simplify the process, making it more manageable for healthcare professionals to continue their valuable contributions to patient care.

Understanding Minnesota Uniform Credentialing Application

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

The Minnesota Uniform Credentialing Application form is designed for the use of physicians, dentists, and allied health professionals seeking reappointment. Its primary purpose is to streamline the credentialing process by collecting comprehensive personal and professional information, including education, training, employment history, and any affiliations with hospitals or other medical institutions. This uniform application aids in ensuring that healthcare providers meet the necessary standards and qualifications for the provision of medical care.

Who needs to complete the Minnesota Uniform Credentialing Application form?

The form must be completed by physicians, dentists, and allied health professionals who are seeking reappointment within their practice area. This includes those applying for reappointment at hospitals, clinics, and other healthcare institutions that require credentialing as part of their professional engagement.

What information is required in the application?

Applicants are required to provide detailed personal data, contact information for credentialing purposes, and information regarding their practicing status, such as whether they are accepting new patients. Additionally, the form solicits information on primary and additional practice locations, fellowship/post-graduate/professional training history, academic and professional affiliations, a chronological employment/practice history, hospital affiliations, and explanations for any gaps in the professional practice. Affirmative disclosures to certain questions also require detailed explanations.

Are there any specific instructions for completing the form?

Yes, applicants must ensure the form is filled out completely and accurately. Information should be legible and may be electronically generated. Abbreviations should be avoided, and any additional sheets attached should reference the specific question being answered. All signatures and dates must be clearly legible. It's also important to provide complete contact information where indicated, designate dates in the specified month/day/year format, and sign the attestation and release sections.

What should I do if I need more space to answer a question?

If additional space is needed to provide a complete answer to any question, applicants should attach extra sheets of paper to the application. Each attachment should clearly reference the question number or section it pertains to, ensuring that reviewers can easily understand the context of the information provided.

How do I indicate gaps in my employment or practice history?

Applicants must provide a chronological listing of their employment/practice history, explicitly noting any gaps or interruptions longer than three months since the last reappointment. Each gap should be explained on the form or an attached addendum, with the explanation detailing the reasons for the interruption in practice.

What are the requirements for the Attestation Signature and Authorization and Release sections?

In the Attestation Signature section, the applicant asserts the accuracy and completeness of the information provided in the application. Signing the Authorization and Release section grants permission for the requisite entities to obtain further information necessary for verifying the applicant's credentials and qualifications. Both sections must be signed and dated by the applicant, ensuring all provided information can be validated.

Can I submit the application electronically?

While the instructions specify that information should be printed in black ink or electronically generated, it does not explicitly state whether the form can be submitted electronically. Applicants should consult with the institution or body to which they are submitting the form to determine if electronic submission is acceptable.

What happens if I use abbreviations in the application?

Applicants are advised not to use abbreviations when completing the application. This is to ensure clarity and prevent any misunderstandings or errors in processing the application. It's important to use full names, titles, and descriptions throughout the application to ensure the accuracy of the information provided.

Common mistakes

Filling out the Minnesota Uniform Credentialing Application accurately is crucial for healthcare professionals. However, several common mistakes can lead to delays or issues in the credentialing process. One of the first mistakes is not providing complete contact information. The form requires detailed information, including street addresses, phone, fax, and e-mail addresses for a variety of sections, such as education, training, past employment, hospital affiliations, and references. Omitting any part of this can stall the application.

Another error involves not designating dates properly. The application specifies that dates should be presented in month, day, and year format. Failure to follow this format can create confusion and potentially delay the processing of the application. This mistake is easily avoided by double-checking all dates before submitting the form.

A significant mistake is not answering the Disclosure Questions on Pages 10 and 11 thoroughly and failing to enclose explanations for affirmative answers. This oversight can raise red flags during the credentialing process, as these questions are designed to identify any issues that need to be addressed or clarified.

Applicants often forget to sign and date the Attestation Signature and Date statement on Page 12 and the Authorization and Release on Page 13. These signatures are vital, as they verify the truthfulness of the information provided and authorize the release of information for credentialing purposes. An unsigned application is incomplete and cannot be processed.

Ensuring the application and all attachments are legible or electronically generated is another step that is frequently overlooked. Illegible handwriting or poor-quality copies can lead to misinterpretation of information, requiring the credentialing staff to seek clarification or additional documentation.

Using abbreviations instead of full terms is another common error. The application instructions specifically advise against this practice to ensure clarity. Every field and description should be written out fully to avoid any confusion or misinterpretation of the information provided.

Last but not least, failing to provide additional sheets when more space is needed is a mistake that can lead to incomplete information being submitted. The application allows for attaching extra pages for comprehensive answers, ensuring that applicants can provide thorough and detailed information as required.

Addressing these common mistakes can streamline the credentialing process, ensuring that healthcare professionals provide the necessary information accurately and completely, facilitating timely approval and credentialing.

Documents used along the form

When completing the Minnesota Uniform Credentialing Application, healthcare professionals often need to submit additional forms and documents to provide a complete profile of their qualifications and history. These documents are crucial in the credentialing process, ensuring that the information provided is comprehensive and accurate.

Current State Medical License: A copy of the applicant's current state medical license is essential. This document verifies that the healthcare professional is legally permitted to practice medicine in the state of Minnesota. It provides credentialing committees with the assurance that the applicant meets state regulatory requirements.
Board Certification Document: For those professionals who are board certified, a document confirming their certification status is required. Board certification demonstrates a physician's expertise in a particular specialty or subspecialty, signifying that they have met the rigorous standards set by a recognized certifying board.
Professional Liability Insurance Certificate: This document serves as proof that the applicant has appropriate malpractice insurance coverage. It indicates the policy's effective dates and coverage amounts, which are critical for protecting both the healthcare provider and their patients in the event of a liability claim.
Continuing Medical Education (CME) Certificates: CME certificates are needed to demonstrate that the healthcare professional has participated in ongoing education relevant to their field. Continuing education is integral in ensuring that providers remain up-to-date with the latest advancements in medical care and technology.

Together with the Minnesota Uniform Credentialing Application, these forms and documents paint a full picture of the healthcare professional's background, education, and qualifications. This comprehensive approach supports a thorough credentialing process, essential for maintaining high standards of care within the medical community in Minnesota.

Similar forms

The Minnesota Uniform Credentialing Application form shares similarities with the American Medical College Application Service (AMCAS) application, frequently used by prospective medical students for applying to medical schools in the United States. Both applications require detailed educational histories, including specifics about institutions attended and degrees earned. The AMCAS, similar to the Minnesota form, mandates personal identification details and a chronological listing of educational and professional experiences, designed to offer a comprehensive view of the applicant’s background and qualifications for the intended medical role.

Like the Electronic Residency Application Service (ERAS) application used by graduates seeking residency positions, the Minnesota Uniform Credentialing Application form collects extensive personal and professional information. This includes a detailed employment history, affiliations with medical or professional institutions, and any gaps in education or employment. Both applications serve as a centralized means for candidates to present their qualifications, including educational achievements, professional experiences, and personal competencies, to multiple reviewing bodies or programs.

The National Practitioner Data Bank (NPDB) Query Authorization form and the Minnesota Uniform Credentialing Application both play critical roles in the credentialing process. Each requires the applicant's authorization to allow hospitals or employing agencies to perform background checks essential for verifying the credentials and history of medical practitioners. These checks help in assessing the suitability of individuals for clinical responsibilities, ensuring they meet the rigorous standards set by healthcare institutions.

The Federation Credentials Verification Service (FCVS) application, much like the Minnesota form, collects detailed professional information, which includes certifications, licensure, and educational background of healthcare professionals. Both are instrumental in streamlining the verification process for medical credentials, simplifying the procedure for healthcare providers to be recognized across different states and healthcare systems, thus facilitating mobility and employment opportunities.

Similarly, the Common Application Form (CAF) for privileged healthcare providers is used to apply for hospital privileges or membership in medical associations, much like the Minnesota Uniform Credentialing Application. They gather comprehensive data, including education, training, work history, and references, to assess the qualifications and competencies of healthcare professionals. Both forms are integral in the decision-making process for granting clinical privileges or association memberships, ensuring applicants meet the institutions' standards.

The Health Insurance Portability and Accountability Act (HIPAA) Authorization form and the Minnesota form share the necessity for applicants to authorize the release of specific health information. This authorization is crucial for verifying the information provided in their application, such as past employment and educational credentials, and ensuring compliance with privacy regulations. Both serve to protect the privacy of the individuals involved while allowing necessary checks to be conducted.

Likewise, the Professional Liability Insurance Application and the Minnesota Uniform Credentialing Application request detailed personal information, educational background, and professional experience. Both are used to assess risk and eligibility – the former for insurance coverage determination and the latter for credentialing purposes. Information about past employment, any gaps in professional practice, and prior affiliations with medical institutions are critical for evaluating the applicant's qualifications and ensuring they meet the high standards expected in their respective fields.

Dos and Don'ts

When completing the Minnesota Uniform Credentialing Application form, it's essential to follow specific guidelines to ensure the application process is smooth and successful. Here's a comprehensive list of what you should and shouldn't do:

Things You Should Do:

Provide complete contact information: Ensure that all sections asking for your address, phone number, fax number, and email are filled out accurately. This includes information related to your education, training, past employment, hospital affiliations, and references.
Use clear and legible handwriting or type electronically: It's crucial that all information is easy to read to avoid any delays in the credentialing process.
Answer all the questions thoroughly: This includes designating dates by month, day, and year. If additional space is needed, attach extra sheets with references to the questions being answered.
Provide detailed explanations when necessary: If you answer affirmatively to any of the disclosure questions, make sure to include a detailed explanation as requested.
Sign and date the form: Make sure the attestation signature and date statement, as well as the authorization and release sections, are signed and dated. Your signature is a key part of verifying the authenticity of your application.
Use black ink for printing or typing: This ensures that all the information is clearly visible and easily photocopied if needed.

Things You Shouldn't Do:

Avoid using abbreviations: Spell out words completely to ensure clarity. Abbreviations can lead to confusion and may not be understood by all reviewing your application.
Do not leave spaces blank: If a question does not apply to you, it's better to write "N/A" for "not applicable" than to leave the space blank. This shows that you did not overlook the question.
Refrain from submitting incomplete applications: Check all parts of the application to ensure that you have not missed any sections or required documentation.
Avoid unclear explanations: When providing explanations for affirmative answers to disclosure questions, be clear and concise to avoid any misunderstandings.
Do not use colored inks: Using inks other than black can make the application difficult to copy or fax, potentially causing delays in processing.
Do not forget to check for additional employment history or gap explanations: If you have more information than what fits on the application, remember to indicate that extra documents are attached as required.

Misconceptions

There are several misconceptions regarding the Minnesota Uniform Credentialing Application form. Let's clarify some of the most common ones:

It's only for physicians. While the application is heavily utilized by physicians, it's also designed for dentists and allied health professionals. This includes a wide range of healthcare providers, indicating its broad applicability beyond just doctors.
Electronic submissions aren't allowed. The application details specify the need for legibility, whether the form is filled out by hand or electronically generated. This implicitly allows for electronic submissions, as long as they meet the legibility and completeness standards.
Abbreviations are acceptable. The instructions clearly advise against the use of abbreviations. This ensures clarity and prevents misunderstandings in the credentialing process.
All sections must be completed by everyone. Certain sections specify when they should be completed. For example, a box indicates it's to be completed by allied health professionals only. Not every section applies to every applicant.
It's okay to leave employment gaps unexplained. The form requires applicants to explain any gap or interruption in their practice of medicine or professional practice that's greater than three months. This is vital for a thorough credentialing review.
It doesn't matter if information is printed in colors other than black. The application explicitly requires all information to be printed in black ink or electronically generated. This likely aids in ensuring uniformity and legibility of applications.
References aren't necessary. While the form doesn't explicitly mention references in the provided snippet, giving complete information about education, training, past employment, hospital affiliations, etc., will inherently involve providing references.
Signatures and dates can be in any format. The instructions specify that all signatures and dates must be clearly legible, emphasizing the need for clear, easily readable information to process the application correctly.
You can use the form for initial credentialing. The title of the form specifies it's for reappointment, implying it's not intended for first-time credentialing applications. It's meant for those who are reaffirming their status within a system they're already part of.
Language fluency doesn't need to be specified. The form asks if the applicant can speak a language other than English fluently enough to treat patients who only speak that language. This detail is crucial for ensuring effective communication with all patients.

Understanding these aspects can help streamline the application process, ensuring that all information is presented accurately and efficiently.

Key takeaways

Completing the Minnesota Uniform Credentialing Application accurately is essential for healthcare professionals seeking reappointment. This process is not only a compliance requirement but also a critical step in ensuring the continuity and quality of patient care. Here are eight key takeaways to consider:

Ensure accuracy and completeness: Fill out the application fully and accurately, including all required contact information, educational background, employment history, and affiliations. Inaccurate or incomplete information can delay the process.
Legibility is crucial: Whether filled out by hand or electronically, the application and all attachments must be legible. If handwriting, use black ink to improve readability.
Avoid abbreviations: Use full names and titles instead of abbreviations to prevent confusion and ensure clarity.
Signatures and dates: All required sections, such as the Attestation Signature and Date statement and the Authorization and Release, must be signed and dated clearly. Illegible signatures can lead to processing delays.
Address gaps in employment: Be sure to explain any gaps in your practice history that are greater than three months. This is critical for a comprehensive credential review process.
Disclose affiliations accurately: List all hospital and professional affiliations since your last appointment. Include the type of affiliation and provide contact information for verification.
Manage additional information: If the space provided is insufficient, attach additional sheets referencing the question being answered. This ensures that all relevant information is captured and reviewed.
Language proficiency: If you are fluent in languages other than English, specify which ones. This is important for matching patient needs and improving the quality of care.

Filling out the Minnesota Uniform Credentialing Application with attention to these details will facilitate a smoother reappointment process, helping healthcare professionals maintain their practice and provide high-quality care to their patients.

Please rate Free Minnesota Uniform Credentialing Application Form in PDF Form

4.67

(Exceptional)

3 Votes

Additional PDF Templates

Marriott Family and Friends Form - Explore the benefits of Marriott's Friends and Family Rate by downloading the authorization form.

Real Estate Sales Validation Form - The physical address of the conveyed property is also a requirement, providing a specific location for record purposes.

California S Corp Extension - Prepayments of the franchise tax need to be detailed, including mandatory and any optional installments paid.