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?
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
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