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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.)



Partner, Associate,

Or Covering

Telephone Number

(   )    -

(   )    -

(   )    -

(   )    -

Admitting Service

Do you admit patients to the hospital under your own service?

If no, to whom do you admit?

Yes No NA

Practitioner Extenders

Please check any of the following practitioner extender types and list

individual names who you either employ or utilize for direct patient care.

Physician’s Assistant:  

Nurse Practitioner:  

Nurse Midwife:  

Other (specify):  

Workers’ Compensation Information

Do you accept Workers’ Compensation Patients?

Yes No

If yes, please provide the following information:

Note:  Section 3 (Medical/Professional Education) and Section 4 (Professional Training) have been intentionally omitted.  If additional formal education/training has been obtained since the date of last credentialing, please complete Sections 3 and 4 from the Credentialing application as appropriate and attach.

a.Are staff trained in identification and care of patients with work-related illness/injury and provide care/services with an active return to work philosophy? Yes No

b.Modified or alternative duty is actively evaluated for each Workers’ Compensation claimant. Yes No

c.Office will accommodate urgent walk-ins (or non-urgent appointments within 48 hours) to treat injured or ill workers and facilitate their return to work, if possible. Yes No

d.Staff are available and willing to provide compensation representatives information regarding a claimant’s care. Yes No

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 5

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