Applications

Medical Malpractice Insurance

ACUTE CARE, INC. will include you under its professional liability insurance coverage, which will insure you while you are providing services at all affiliated hospitals. The policy is a 'claims-made' policy, which means you are covered for claims or suits arising from the performance of professional services after the retroactive date shown on the policy and first made or brought against you while the policy is in force. If tail coverage is needed, this is provided at the expense of ACUTE CARE, INC.

Credentials Checklist

In order to expedite the credentialing of your application it is necessary all of the following information is returned:

• In addition to the above forms, please include a COPY of the following documents
  • Limited Power of Attorney
  • W-9 Form (Physician)
  • W-4 & I9 Form (Mid-Level)
  • Curriculum Vitae (CV)
  • Continuing Medical Education Documentation-CMEs (Within the last 2 years)
  • Medical Training Certificate
  • ECFMG Certificate (if applicable)
  • Internship/Residency Certificate(s)
  • Board Certifications (if applicable)
  • NCCPA Certification (Mid-Level)
  • State Medical License Wall Certificate
  • Current State License(s) Card Copy
  • Current State Controlled Substance Certificate (CSA) - If applicable
  • Current Federal DEA Certificate
  • Visa/Alien Registration/Work Permit for USA if you are not an American Citizen
  • Current certifications - ACLS (Required), ATLS, PALS
  • Health Statement & Physical Health Statement Forms (Physician)
  • T.B. (within the last year) and Rubella Vaccination Documentation
    If TB PPD+ send TB test, chest x-ray, & complete Health Status Information Questionnaire for TB PPD
  • Government issued photo ID (Driver's License)
• Medical Staff Application - Please be sure that this is filled out in its entirety.
• ACUTE CARE, INC. Application for Medical Staff Membership Consent Form
• ACUTE CARE, INC. Agreement - This will be sent to you after we receive your information, please be sure to have it signed and dated. Please sign and forward both copies as we will sign and return an original to you.
• ACUTE CARE, INC. Delineation of Privileges (Emergency Medicine, Family Medicine or Mid-Level)
• ACUTE CARE, INC. Claim Information Form - If you answered 'yes' to either of the questions under the Liability section on your application, you must complete this form in detail. Also provide any supporting documents you may regarding the claims.

This Credentials Checklist will assist you in determining which forms and documents need to be returned. It is important that the application packet be received back in its entirety so your application may be processed without delay.