Healthcare Credentialing Application Supplement

Healthcare Credentialing Application Supplement — Form Fields

This healthcare template includes 13 fields. New clinical staff complete supplementary credentialing information for medical staff office review. Free to customize and use on ZenBuild.

• Applicant Full Name (text, required)
• Work Email (email, required)
• NPI Number (text, required)
• Provider Type (dropdown selection, required) — options: MD, DO, NP, PA, CRNA, CNM, LCSW, Other
• Medical School or Training Program (text, required)
• Residency Completion Date (text, required)
• Fellowship (if applicable) (text, optional)
• Board Certification Status (dropdown selection, required) — options: Board Certified, Board Eligible, Not Applicable
• DEA Registration Number (text, required)
• State License(s) (dropdown selection, required) — options: Single State, Multiple States
• Malpractice Claims in Past 5 Years? (dropdown selection, required) — options: Yes, No
• Explanation for any Yes answers (long text, optional)
• I certify all information is accurate and complete (checkboxes, required)