CREDENTIALING CHECKLIST - PHYSICIAN

1. Personal Information
□ Full Name, Date of Birth, Home Address, Phone #, Personal Email
□ City, State, Country of Birth
□ Copy of Driver’s License 
□ Social Security # / Copy of Social Security Card
□ Digital color copy of a picture (Headshot)
□ Proof of Citizenship (Passport or Birth Certificate)
□ NPI #
□ Languages spoken fluently

2. Education & Training (Copy of: )
□ Medical Diploma
□ Bachelors Diploma (Masters if applicable)
□ Internship
□ Fellowship 
□ Residency
□ ECFMG (if applicable)
□ USMLE Number and Exam Date (if applicable)
□ CME credits

3. Work History
□ Updated CV 
     ▪ List any gaps in employment greater than 3 months 
     ▪ Please make sure that dates and addresses are included in the following format 
(MM/DD/YYYY)
□ Other locations practicing in addition to EPIC
□ Archived or rejected locations

4. Licenses & Certificates 
□ State of Michigan Physician License 
□ State of Michigan Controlled Substance Registration (CDS)
□ DEA License
□ Board Certification / Name of Board & Certification Date
    ▪ Secondary Specialty (if applicable)
□ CMEs – Credits and MM/YY completed
□ BLS/ACLS Certificates (not required)
□ Special Skills & Training: Patient populations, Physical Conditions, Behavioral Conditions, 
Therapeutic Methods and Tools
□ Other Certifications (not required)
   ▪ QASP, CPR, ALSO, CoreC, ATLS, NALS, NRP, PALS

5. Malpractice/Liability Insurance 
□ Copies of current/previous medical liability insurance including Tail Coverage if that applies.
□ Information on any malpractice claims (if applicable)

6. Peer References 
□ 4 (at least 3 in your specialty that are not currently part of our practice)
    ▪ Please include the following information
    • Name
    • Title
    • Phone number
    • Email Address
    • Relationship
    • How many years known

7. User ID and Passwords
□ CAQH (888-599-1771)
□ PECOS (Medicare: 866-484-8049)
□ NPPES
□ CHAMPS (Medicaid)

8. Medical Documentation
□ Proof of Current Flu Vaccination 
□ Proof of Current TB Test Completed
□ Immunizations

9. Facility/Hospital Affiliations (Current & Prior)
□ Denied affiliations

10. Digital Signature document