Service Catalog
CMED FSA (Faculty & Staff Affairs)
CMED FSA Credentialing

CMED FSA Credentialing

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CMED FSA Credentialing form is designed to collect information about possible CMU Employees

Please complete all answers fully. If there is a break in the continuity of your medical education, internship, residency, hospital affiliations, medical practice etc. please explain in the space provided. You will also need to provide (attach) copies of:

your CV
current state license
narcotic registration (DEA and CDS)
declarations page of professional liability insurance policy including applicants name, effective date, expiration date, any policy limits
board certification
professional school/diploma
residency certificates
fellowship certificates
copy of your drivers’ license.

This is a secure website form and your information will not be shared outside of CMU.

Title

A short description to explain the nature of a ticket.

Please confirm your full name (First, Middle, Last)

List other name(s) by which you have been known

Full Social Security Number

Date of Birth (mm/dd/yyyy)

Place of Birth

Country of Birth

City, State, County of Birth as applicable

Citizenship

US Citizen

Non-Resident Alien

Non-Citizen National of US

Permanent Resident

Other (please explain)

Other Citizenship - Please Explain

Gender

Woman

Man

Non-binary

Prefer not to answer

Preferred Mailing Address including City, State, and Zip Code

Preferred Contact Phone Number including Area Code

Preferred Business Address including City, State, and Zip Code

Preferred Business Phone

Undergraduate Education Please include the College or University Name, Address (city, state, country), degree received, and date degree earned mm/yyyy

Medical Professional Education Please include the College or University Name, Address (city, state, country), degree received, to and from dates, and date degree earned mm/yyyy

Other Postgraduate Education Please include the College or University Name, Address (city, state, country), degree received, to and from dates, and date degree earned mm/yyyy of additional postgraduate education. Indicate N/A as necessary

Residencies Please include the Hospital, Healthcare Organization, College or University Name, Address (city, state, country), program specialty, to and from dates, mm/yyyy of any residency(s). Indicate N/A as necessary

Fellowships Please include the Organization, College or University Name, Address (city, state, country), program specialty, to and from dates, and, if any, degree mm/yyyy of any fellowships. Indicate N/A as necessary

Providers at CMU College of Medicine are responsible for obtaining the appropriate licensures to practice medicine in the State of Michigan and are also responsible for maintaining active and current licensure for patient care. Licensed status must be maintained for the duration of your appointment.

Michigan State Medical/Professional License Number

Michigan State Controlled Substance Number

Drug Enforcement (DEA) Administration Certification Number

Please provide your NPI Number

Please provide your CAQH Provider ID

Please enter other State Licenses below. Be sure to include the State and License Number. Please include your ECFMG Number if applicable.

Please enter your board or other professional certifications. Please include the Name of the Issuing Board, Specialty, Date Certified/Recertified, and the Expiration Date (if any)

Please enter your professional liability information including the name of your Insurance Carrier with Address and Phone, Policy Limits, Per Occurrence $, Aggregate $, Policy Number and the effective and expiration dates.

Please answer all of these questions Yes or No. An affirmative answer to any of these questions may not automatically disqualify you but may result in further follow-up for credentialing purposes

Do you have or have you ever had a license revoked, suspended, denied, restricted, limited or issued/placed on a probationary status or voluntarily relinquished?

Do you have or have you ever had a license revoked, suspended, denied, restricted, limited or issued/placed on a probationary status or voluntarily relinquished? Yes No

Have you ever had a DEA certificate revoked, suspended, limited, restricted in any way or voluntarily relinquished?

Have you ever had a DEA certificate revoked, suspended, limited, restricted in any way or voluntarily relinquished? Yes No

Have you ever voluntarily not renewed your DEA license, Medical or Dentistry License in any state?

Have you ever voluntarily not renewed your DEA license, Medical or Dentistry License in any state? Yes No

Have you ever been terminated, placed on probation or otherwise disciplined from a residency program or medical staff?

Have you ever been terminated, placed on probation or otherwise disciplined from a residency program or medical staff? Yes No

Have your privileges at any hospital ever been refused, suspended, diminished, revoked, or not renewed?

Have your privileges at any hospital ever been refused, suspended, diminished, revoked, or not renewed? Yes No

Have you ever voluntarily withdrawn your privileges or resigned from any hospital or training program?

Have you ever voluntarily withdrawn your privileges or resigned from any hospital or training program? Yes No

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any medical organization?

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any medical organization? Yes No

Have you been named (individually or through an entity) in a medical malpractice or professional liability case?

Have you been named (individually or through an entity) in a medical malpractice or professional liability case? Yes No

Are you now, or have you ever been, involved in administrative, professional, or judicial proceedings in which malpractice on your part is or was alleged?

Are you now, or have you ever been, involved in administrative, professional, or judicial proceedings in which malpractice on your part is or was alleged? Yes No

Have you ever been subject to any disciplinary action for academic or personal misconduct or other reasons in any of the colleges, universities, graduate or professional schools you have attended?

Have you ever been subject to any disciplinary action for academic or personal misconduct or other reasons in any of the colleges, universities, graduate or professional schools you have attended? Yes No

Have you ever been convicted of (or pled no contest to) a crime other than a minor traffic violation?

Have you ever been convicted of (or pled no contest to) a crime other than a minor traffic violation? Yes No

Have you ever been convicted of (or pled no contest to) a felony?

Have you ever been convicted of (or pled no contest to) a felony? Yes No

Are you aware of any criminal charges pending or expected to be brought against you?

Are you aware of any criminal charges pending or expected to be brought against you? Yes No

Do you have any contagious or communicable diseases that could endanger others?

Do you have any contagious or communicable diseases that could endanger others? Yes No

Have you ever been addicted to or dependent upon intoxicating liquor, narcotics or other illegal substances?

Have you ever been addicted to or dependent upon intoxicating liquor, narcotics or other illegal substances? Yes No

In accepting employment at the CMU Collee of Medicine, I certify that the statements in this application are true and complete, and I understand and agree that misstatements or omissions in this application may be grounds for summary dismissal and/or denial or termination of employment. I agree to immediately report any changes to: (1) the answers to the above questions; (2) in the status of my medical license; or : (3) in my status at other institutions or medical centers to the Assistant Dean, Faculty & Staff Affairs.

I will be responsible for the medical care of the patient, for prompt and accurate completeness of medical records, for transmitting reports of the patient's condition to concerned parties who are entitled to such information, and for providing or appropriately arranging for continuity of care.

I agree to report any changes in my health status that could adversely affect my ability to practice medicine and agree, with reasonable cause, to submit to a physical exam, drug and alcohol screens or their assessments acceptable to Faculty and Staff Affairs, should they be considered necessary.

If I am ever under investigation by any regulator agency, I am responsible for immediately informing the Assistant Dean, Faculty & Staff Affairs of the agency involved, the basis of the complaint, any intermediate measures (such as temporary licensure probation or suspensions), and the final resolution or outcome.

I recognize it is my responsibility, and mine alone, to maintain appropriate licensure at all times. I agree to abide by all rules and regulations regarding same and I realize it is unlawful to practice medicine without an active license.

I hereby authorized agents of the University to consult with other universities, hospitals, and members of their medical staffs, with licensing boards, and with anyone who may have information bearing on my competence, my character, or my professional or ethical qualifications. I further authorize agents of the University inquiries from any individual hospitals, boards, and courts concerning any claims, lawsuits, disciplinary actions, license restrictions or denials, or any other matters affecting my ability to practice my profession. I hereby consent to the release from any source, including information that would otherwise be privileged or confidential, to CMU College of Medicine, of any and all information concerning my conduct and abilities to practice medicine.

I hereby authorized and release from liability the CMU College of Medicine and all other entities, insofar as the University provides information from my credentialing file including information that is confidential and/or privileged, or permits access to my file to any other entity with a need to independently evaluate or verify my credentials, or audit CMU College of Medicine's credentialing process and decisions.

I release from liability all individuals and organizations that provide information concerning my qualifications. I further release from liability the CMU College of Medicine, its trustees, employees, officers, and agents, who make inquiries concerning my conduct and abilities to practice, and I hereby indemnify them from any claim arising from their consideration, award, denial of my employment application or termination of my employment.

I certify that the information submitted on this application is complete and correct to the best of my knowledge. I understand that any false, misleading, or missing information may be cause for withdrawal of appointment or employment, or an adverse employment action up to and including termination of employment.

Your typed name below indicates you have read and agree to the above statements. Please enter your name and the date below.

Please enter your full name and todays date

Please download, complete, and then attach this additional form for malpractice insurance.
Click HERE to download (then complete and attach).
You will also need to include any\all of the following documents: your CV, state license narcotic registration (DEA and CDS), declarations page liability insurance including name, effective date, expiration date, limits, board certification professional school/diploma, certificates, copy of your drivers License

Attachments get attached here! Don’t forget to include the malpractice Insurance form that was also emailed to you.

File attachments associated with the ticket.

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Your name

Your first name

Your last name

Your email address