Requests to add NEW CLINICAL PROVIDERS* are to only be completed and submitted by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates. The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes and does not meet participants’ independent credentialing or other required hiring background, screening, and/or on boarding processes.
FMMJUA Specialty Descriptions for use with the below.
* Providers (employees or volunteers) who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.
Professional Liability Questionnaires (PLQ)** are required for all new hires or volunteers with clinical exposure, or for existing employees or volunteers with newly added clinical exposures, practicing under the following license types: MD, DO, DDS, DMD, DPM, SVM, PhD, PsyD, PharmD, PA, AA, LSW, LBSW, LMSW, LCSW, LMHC, PLC, ARNP, CNM, CM, and CRNA. Please be sure to attach the required PLQ, as well as the provider’s CV and Letter of Offer, if applicable and available, to this submission.
** If needed, the PLQ template can be found here: Coverage Forms – Self-Insurance Programs Self-Insurance Programs
* below indicates a required field