PPO PRACTITIONER DATA SHEET

Practitioner Name (first, middle, last and credentials) / Credentialing Application Completed Online? YesNo
Specialty / Sub-Specialty / Effective Date with Care Site
CREDENTIALS
Date of Birth / Social Security Number / Male Female
State License Number(list all) / License Issue Date(s) / License Expiration Date(s)
State License Number / License Issue Date(s) / License Expiration Date(s)
DEA Number / DEA Issue Date / DEA Expiration Date / DEA Schedules (list)
Individual NPI / Taxonomy Code(primary) / Secondary Taxonomy Code (if app)
Practitioner’sE-mail / Clinic Contact E-mail
Specialized Training/Certification / Board Certification / Date
List language(s) other than English, that are spoken/written with fluency and do not require an interpreter when communicating with patients? Please list:
VOLUNTARY INFORMATION
Providing race and ethnic background and language information is voluntary. Group Health is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and quality reporting and regulations. To comply with these laws, we invite you to self-identify your race and ethnicity and spoken and written languages. This information will only be used in accordance with the provisions of applicable laws and regulations that require the information to be summarized and reported. When reported data will be in aggregate and not identifiable at any specific individual level. Your answers are both voluntary and private.
Ethnicity:
Do you consider yourself Hispanic or Latino? Please choose one.
Yes, Hispanic or Latino:
A person of Cuban, Mexican, Puerto Rican, South or Central American, or Spanish culture or origin, regardless of race.
Not Hispanic or Latino
Don’t know
Decline to answer / Race:
Which category best describes your race? You may choose one or more.
American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent include, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Other
Don’t know
Decline to answer

Page 1 of 1Revised 04/10/14