Clinically Integrated Network

Provider Evaluation and Credentialing Request Form

This form needs to be completed for every provider who will be caring for patients. Upon submission, the Affiliate Team will initiate the pre-vetting review and reach out to the submitter for additional information and steps to complete the pre-vetting review and UCSF credentialing.


Please DO NOT submit a credentialing pre-application for this provider, as this will be completed by the Affiliate Team on your behalf after successful pre-vetting.


Please submit at least 120 days prior to the provider's intended start date to allow for pre-vetting and credentialing timelines.


For questions, please contact Jamee Black at jamee.black@ucsf.edu or Pete L'Engle at pete.lengle@ucsf.edu.

 

 

Is this provider an additional provider, a replacement provider, or a locum tenens?

 
 
 
 
 
 
 
 
 
 
 
 

If no current California license, please indicate if 'in process'

 
 
 
 

 

Please upload the following : CV / resume, copy of front and back of driver's license (or other government ID), signed / completed Provider Evaluation Agreement, completed credentialing signature form; and, for Nurse Practitioners, a copy of their Board Certification Certificate.

Drop your files here
 

Enter the encrypted DOB and full SSN here.


To encrypt, please go to the website https://codebeautify.org/encrypt-decrypt and switch the 'Algorithm' to "blowfish". Then for the 'Key' enter a passcode that we will share offline and can use over and over with your group. Then, enter the SSN and DOB on separate lines in the "Enter the Plain or Cypher Text" section and press encrypt. The encrypted code will appear in the "result" section. Copy and paste that result here.


https://codebeautify.org/encrypt-decrypt

 

that the provider will have when they join your group

 

that the provider would have when they join your group

 

that the provider will have when they join your group (include address, city, state, zip)

 

that the provider will have when they join your group (include address)

 

for the clinic where the provider will work at when they join your group

 

for this provider when they join your group