Use ONLY by UF Health MSO - Self-Insurance Programs_ Self-Insurance Programs

UFH MSO Request for Provider Healthcare Professional Liability Verification

Date of Request *

RUSH: Due in less than 10 business days? *

NO
YES

Submitting requests as far in advance as possible is essential to our processes and workflows. Marking requests as a RUSH should be infrequent and require an MSO leadership directive.

Date Verification Due By *

NOTE: Date MUST be within 90 days of anticipated hire date below (if new provider).

MSO: Name of Requestor *

First

Last

MSO: Phone *

MSO: Email *

MSO Office *

Date of Credentialing Meeting

Healthcare Provider Information

Provider Name *

First

Last

Provider License #, including prefix (e.g., ME, APRN) *

Provider UF ID # (if available)

Provider is … *

If "Other" selected above, please explain.

If "New Hire" or "Current Resident to be hired as Faculty" selected above, what is the anticipated hire date?

Provider is/will be employed by which UF College AND Department -or- UF Health Shands Hospital? *

This verification is needed for which UFH facility/facilities?

If "Other" selected above, please explain.

Provide name and email/phone # for the department/service contact/lead for this provider. *

Optional: Comments

Optional: Please upload documents that may assist with this request.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please allow up to 10 business days for processing except for those noted as a RUSH above. We will exhaust all efforts to ensure completion by the stated due date.

For questions related to the process or status of your request, please call us at 352-273-7006.

Thank you,

SIP Insurance Services, University of Florida JHMHC Self-Insurance Program (SIP)