Please complete this form in order to process your credentialing profiles and applications. In addition to this information, we will need a copy of your current resume (in month/year format), transcripts, a current driver's license, and any certifications you may hod (such as a DEA, ANCC, or board certification). Credentialing will not begin util all of these documents are received.

*Disclaimer - For the following, if you are not currently enrolled in NC Medicaid you may enter N/A.

Disclosures: If you answer yes to any of these questions, we will need documentation of the occurrence and its outcome. We will also need a signed personal statement from you to include with your profile.

In addition to a written explanation, any actions against clinical licenses or prior convictions (other than a minor traffic violation) will require documentation from the board or court documentation from the occurrence.

Answering these questions inaccurately could cause your credentialing applications to be denied.

Question 1

Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied, or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under investigation by any licensing or regulatory agency?

Question 2

Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason?

Question 3

Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under threat of investigation or are any such actions pending?

Question 4

Have you ever been sanctioned or suspended by Medicare or Medicaid?

Question 5

To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners?

Question 6

Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to such conduct?

Question 7

Has a professional liability claim been assessed against you in the past five years, or are there any professional liability cases pending against you?

Question 8

Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage?

Question 9

Have you ever practiced without liability coverage?

Question 10

Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential function of your position?

Question 11

Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending?

Question 12

Do you give permission for Capeside Psychiatry to act on your behalf to prepare, complete, and maintain credentialing and network participation applications? (Please note that you will always maintain access to your profiles, but Capeside Psychiatry requires access in order to ensure that the provider you are contracted with can bill for services.)

If you have questions regarding this form, please reach out to us for more information at:

credentialing@capesidepsychiatry.com

Thank you.