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.)
Professional Liability Information Addendum
(Photocopy this form for each case/action)
Please supply the following and sign and date this form:
Information for each professional liability action you have had taken against you, with any actions or change of status SINCE LAST DATE OF CREDENTIALING, including those pending.
Information for each settlement, or decision for the plaintiff that has occurred on your behalf SINCE LAST DATE OF CREDENTIALING.
Practitioner Signature and Date
All information is held in strict confidence and used for credentialing and recredentialing purposes only. Failure to supply sufficient details may prevent your application from being approved. In addition to completion of this form, practitioner may also submit any additional supporting documentation.
Check here if entire section is not applicable to applicant (and sign below even if no suits or settlements).
Check here if no professional liability actions/claims filed (and sign below even if no suits or settlements).
3.Name of Plaintiff
4.Date of Incident
7. What was/is your status in the case?
8.What is the status of the case?
Other, please explain:
Settled Out of Court
Found for Defendant
Dismissed Without Payment
Found for Plaintiff
9. Amount of any Settlement or Award?
10. Date of any Settlement or Award
Please explain the following in detail. (If an item does not apply please check “N/A”)
11.What was the alleged harm to the patient?
12.What were you alleged to have done incorrectly or failed to do?
13.Describe the patient’s illness and related effects of the alleged harm.
14.Describe any other details you believe are pertinent to the case.
15.Identify any other parties named in the suit.
Practitioner Signature (REQUIRED)
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 16