CREDENTIALING PROFILE
Please type or print all of the information requested on this Profile. Incomplete profiles cannot be accepted and will be returned for completion.
I. PERSONAL INFORMATION
NAME
___________________________
Last First Middle
- - / / ___________________________
Social Security Number Date of Birth Taxpayer Identification Number
To help us comply with the State of Tennessee Diversity Program, would you please check the appropriate boxes?
____Male ____Asian _____Black ____Caucasian
____Female ____Hispanic _____Other ____Prefer not to respond
II. OFFICE INFORMATION
If you have additional offices, please include this information on a separate attachment.
PRIMARY OFFICE SECONDARY OFFICE
Name of Practice Name of Practice
Street Address Street Address
City State Zip City State Zip
Telephone Number ( ) Telephone Number ( )
Fax Number ( ) Fax Number ( )
E-mail Address E-mail Address
Languages Spoken ______________________________________________________________
Please list other licensed dentists in your practice _____________________________________
III. LICENSES
Check appropriate box:
General Practitioner Specialist in ______________________
________________ ____________ _____________________________
TN License Number Expiration Date * National Provider Identifier (NPI)
*Submit original documentation from CMS (Center for Medicare & Medicaid Services)
IV. EDUCATION
__________________________________ ________________ ____________________
Dental School Attended Degree Awarded Year Graduated
V. PROFESSIONAL INFORMATION
A. Does your office comply with the Center for Disease Control and
Prevention (CDC) Guidelines on Infection Control Practices for Tennessee Dentistry?
B. Have you ever been involved in a malpractice suit or claim? _____YES ____NO (If YES, please provide an explanation on a separate sheet of
paper and include dates, nature of the suit, amount of the settlement,
and the name and address of the professional liability insurer involved.)
VI. MALPRACTICE INSURANCE
In order to be credentialed by Delta Dental, you are required to provide proof of professional liability (malpractice) insurance. So that this requirement might be fulfilled, please complete the Authorization Form included on page 4. This authorization permits your carrier/agent to provide us with copies of future renewals; thereby eliminating the need for you to do so. Also, please enclose a copy of the declaration page of your policy.
I authorize the State Board (or any other dental licensing agencies in any state in which I am licensed to practice dentistry) and any health care facility, health maintenance organization or professional organization with whom I have had employment, practice, association or privileges, to release information to Delta Dental of Tennessee regarding my professional skills, any pending or final disciplinary action or malpractice action, and any other information relevant to my character or professional competence. I authorize and request my professional liability (malpractice) insurance carrier to release information to Delta Dental of Tennessee regarding any claims or actions for damages pending or closed, whether or not there has been a final disposition. Further, I authorize such carrier to provide evidence of professional liability coverage to Delta Dental of Tennessee upon its request. I release from liability: a) any person or entity who, in good faith and without malice, provides information to Delta Dental of Tennessee for the purpose of evaluating this Credentialing Profile; and b) Delta Dental of Tennessee for their acts performed in good faith and without malice in connection with evaluating this Credentialing Profile.
I certify that all of the information herein is accurate and true to the best of my knowledge and agree to notify Delta Dental of Tennessee, in writing, of any changes in this document within ten (10) days of their occurrence. I understand that information which is found to be false could result in denial/termination of my participation with Delta Dental of Tennessee.
A photocopy of this permission will be considered as valid as the original.
___________________________________________ ________________________
Dentist's Signature Date
____________________________________________________
Typed or Printed Name
Please include the following when returning this Credentialing Profile:
· A copy of your current license and any specialty certificates
· A copy of your Declarations Page or Evidence of Coverage Page for your Malpractice Insurance
Please fax to (615) 742-6940 or mail all information to:
Delta Dental of Tennessee
ATTN: Professional Relations Department
240 Venture Circle
Nashville, TN 37228
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DDPT-PRL 10 (09/06)