Clinically Integrated Network Provider Evaluation and Credentialing Request Form

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.

Project Type*

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

Select or enter value

Name of Organization Making Request*

Requested by / Contact*

Select or enter value

Provider's Credentialing Contact Email

Desired Work Start Date (if known)*

Provider Full Legal First Name*

Provider Full Legal Middle Name

Provider Full Legal Last Name*

Credentials*

Provider Type*

Select or enter value

Provider Specialty*

Select or enter value

Provider NPI Number*

California Professional License Number*

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

Provider's Current / Preferred eMail Address*

Will provider perform any services atypical for, or outside of, their certified specialty?

File upload

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.

Drag and drop files here or

Identity Code (Provider's SSN / DOB)

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

Name of Supervising Provider (for Advanced Practice Providers)

that the provider will have when they join your group

Name of Professional Liability Insurance Company

that the provider would have when they join your group

Practice Address*

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

Address to send clinical reports (if different than Primary Practice Address)::

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

Clinic Phone*

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

Fax (for clinical reports)*

for this provider when they join your group

Requestor Comments / Notes

Who else should be kept informed?

Select or enter value

Send me a copy of my responses

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