Checklist for New Doctors
ALL ITEMS, IF APPLICABLE TO YOU, ARE REQUIRED. IT IS IMPERATIVE WE RECEIVE ALL ITEMS WITHIN TWO WEEKS OF RECEIPT OF NEW FACULTY BINDER. DELAYS IN SUBMISSION WILL ULTIMATELY EFFECT YOUR START DATE
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Copy of all Medical Licenses, current and previous
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Copy of a current CV
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Copy of medical school diploma, residency, internship certificates, proof of completion
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Clear copy of your current DEA certificate & CSR certificate (if applicable)
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Copy of Board Certifications
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Six (6) photos for inclusion in CAPS, FCVS, and Kentucky license applications 2”x2 COLOR”
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Proof of passing score from Medical Board (i.e. USMLE)
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Copy of all CME’s
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Most recent 2 years TB test results. This year and previous year. If you can not provide two years, you will need to complete another one and include in this packet
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Proof of (2) MMR vaccine and/or positive titer
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Proof of (3) Hepatitis B Vaccine doses and/or positive titer
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NPI username & password so that information can be updated to include UMA provider numbers – CAQH user ID and Password – if you have ever billed insurance under your name, you’ve likely been loaded into CAQH – Your current Credentialing coordinator will know this.
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Malpractice Claim History, Loss run for past 10 years (if applicable)
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Copy of your Social Security card (required by Kentucky Medicaid)
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Documentation of ACLS or BLS certification
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Copy of your Drivers license
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Copy of ECFMG Certificate (if applicable)
One of the following two:
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Case Logs documenting your experience in the privileges you are requesting
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If just completing training, a letter from your Training Director indicating proficiency.
