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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.)

7.Specialty Board Certification:  Complete for information changed SINCE DATE OF LAST CREDENTIALING.  Submit copies of board certifications and/or qualification confirmation letter.

Check here if entire section is not applicable to applicant or if no changes since last credentialing date.

Are you board certified? Yes No(If yes, list below)

Certifying Board Name & Specialty

Initial Certification Date

Most Recent Recertification Date

Next Expiration Date

If not certified, are you qualified to sit for the examination?

Yes No

If not certified, please indicate your status in the certifying process:

Failed to pass specialty board examination

 How many times have you taken the exam but failed

to pass?

 Last date(s) exam was taken: __

Date(s) board examination was taken/retaken and date board exam is scheduled, if applicable:  

Date(s) taken/retaken:   __

Date scheduled, if applicable: _

Not eligible to take specialty boards

Not planning to take specialty boards

Admissible with exam pending

NOTE:  Section 8 (Professional Peer References) has been intentionally omitted; however, may be required by specific entity in which case Section 8 from Credentialing application may be required as indicated on Page 1.

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 8

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