State of West Virginia
Please complete each section thoroughly. Information submitted on the application should be representative of activity/information that occurred or changed on or after the Date of Last Credentialing listed below.
Attach additional sheets where necessary.
(Indicate clearly the practitioner name and section on each attachment)
Type or print clearly in black ink.
Sign and date the application.
Date of Last Credentialing (may be obtained from Entity if not provided)
Social Security Number
Date of Birth
Credentialing Entity Name
YOU MUST INCLUDE THE FOLLOWING WITH THIS
(Use this checklist as a guide)
Copy of current State License(s): For purposes of this application, State License shall include licensure from all 50 states, the District of Columbia, and U.S. Territories
Copy of current DEA Registration (if applicable)
Copy of current State Controlled Dangerous Substance (CDS) Certificate (if applicable)
Copy of current professional liability insurance policy face sheet, showing expiration dates, limits, and practitioner’s name
Copy of Board Certification Certificate(s) (if applicable), or other National Certification Certificates (if changed since date of last credentialing)
Copies of CME/CEU session certificates (if required by Credentialing Entity)
Signature requirements per each entity
Professional Peer References (if required by Credentialing Entity)
CREDENTIALING ENTITIES MAY SUPPLEMENT THIS CHECKLIST OF REQUIRED ITEMS AS NEEDED TO MEET CREDENTIALING REQUIREMENTS.
12/02; 3/03; 11/03; 1/04; 5/04; 10/04 **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 1