New Clinical Privilege/Practice Site Submission Form For Existing Providers

Requests to add NEW CLINICAL PRIVILEGE/PRACTICE SITES  for existing clinical providers* are to be completed and submitted only by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates. 

NOTE:

1. If a new clinical hire, requests to add a NEW PROVIDER should be submitted through the New Clinical Provider Submission Form.
2. If you need to add more than 10 new privilege/practice sites, STOP .. please do not use this process; rather, call your SIP Insurance Services team directly at the following phone # for assistance: 352-273-7006, or 844- MY FL SIP.

The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes only and does not meet participants’ independent credentialing or other required hiring background, screening, and/or on boarding processes.

* Providers (employees or volunteers) who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.

Please complete the below and allow up to seven business days for processing by your SIP Insurance Services Office (ISO).  This form allows for the addition of up to three sites per provider.  If additional sites are needed, a new form will need to be completed and submitted.  Once processed by ISO, the new privilege/practice site(s) will appear in your portal detail.

SELF-INSURANCE PROGRAM *Please SelectUF Gainesville (includes CFH)UF JacksonvilleFSUUCFFAUFIU

SUBMITTED BY

Name *

First

Last

Title *

Phone *

Email *

Clinical Unit *

(e.g., COM Radiology, CON, Student Health Services, etc.)

PROVIDER DETAILS

Clinical Provider Name *

First

Middle

Last

How many Practice Sites would you like to add for this provider? *123

Each Practice Site will need to be added individually.

NEW PRIVILEGE/PRACTICE SITE #1

Name of Facility/Institution #1 *

Zip Code of Practice Location #1 *

Geographic location of practice is a factor in underwriting the exposure. For example, an OBGYN exposure in South Florida is higher than the same exposure in North Florida.

Start Date Privilege/Practice #1 *

The date the provider is to begin delivering healthcare services at this facility.

Is an annual certificate/verification of SIP liability coverage required by the practice site? #1 *SelectYesNo

NEW PRIVILEGE/PRACTICE SITE #2

Name of Facility/Institution #2 *

Zip Code of Practice Location #2 *

Geographic location of practice is a factor in underwriting the exposure. For example, an OBGYN exposure in South Florida is higher than the same exposure in North Florida.

Start Date Privilege/Practice #2 *

The date the provider is to begin delivering healthcare services at this facility.

Is an annual certificate/verification of SIP liability coverage required by the practice site? #2 *SelectYesNo

NEW PRIVILEGE/PRACTICE SITE #3

Name of Facility/Institution #3 *

Zip Code of Practice Location #3 *

Geographic location of practice is a factor in underwriting the exposure. For example, an OBGYN exposure in South Florida is higher than the same exposure in North Florida.

Start Date Privilege/Practice #3 *

The date the provider is to begin delivering healthcare services at this facility.

Is an annual certificate/verification of SIP liability coverage required by the practice site? #3 *SelectYesNo

Comments/Notes

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