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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

11.Time Gaps

Provide information for all time frames of three (3) months or more SINCE LAST CREDENTIALING DATE that are not covered in Hospital/Facility Affiliations and/or Work History/Experience sections (such as extended travel, maternity leave, relocation, etc.).

Check here if entire section is not applicable to applicant.

Section

Dates

Explanation

Hospital/Health Care Entity Affiliations

From:

To:

From:

To:

From:

To:

Work History/Experience

From:

To:

From:

To:

From:

To:

12.Continuing Education Requirements

 Check here if entire section is not applicable to applicant.

A.Have you completed the continuing education hours as required by your State Licensing Board during the past two (2) years OR the required CME/CEU hours (if applicable) from the State licensing board in which you are currently practicing?  

 Yes

 No

B.Attach certificates as noted on Page 1 for the CME/CEU sessions you completed in last two (2) years (if required by Credentialing Entity).

13.Professional Associations/Organizations (optional for recredentialing)

List the associations/organizations related to your profession in which you are a member.  Please include dates of affiliations.  Include faculty appointments.

 Check here if not applicable

Professional Association/Organization

Dates of Affiliation

From: To:

Professional Association/Organization

Dates of Affiliation

From: To:

Professional Association/Organization

Dates of Affiliation

From: To:

Professional Association/Organization

Dates of Affiliation

From: To:

Professional Association/Organization

Dates of Affiliation

From: To:

14.Professional Liability Insurance Coverage:

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 13

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