New Clinical Provider Submission Form

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.

PLEASE NOTE:

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, DMD, DPM, PhD, PsyD, PharmD, and are optional (department/service decision) for DDS, DVM, 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

Self-Insurance Program *Please SelectUF Gainesville (includes CFH)UF JacksonvilleFSUUCFFAUFIU

Submitted By

Name *

First

Last

Title *

Email *

Clinical Unit *

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

Provider Details

Clinical Provider Name *

First

Middle

Last

Appointment CodeEmployeeVolunteer

Email

Cell Phone

Work Phone

Position Title

Clinical/Specialty Description *

Please refer to the FMMJUA Specialty Descriptions included above.

Degree

Example: ME, DO, APRN

License#

Full license # including prefix, (e.g. ME012345)

University or Hospital ID

Start Date *

Hiring College/Service/Hospital *

Examples: College of Medicine, Student Health Services, or Shands.

Department (if applicable)

Division (if applicable)

% assigned/leased to UFCOM

For shared COM/Shands hires only - together with % assigned/leased to Shands should not be greater than 100%.

% assigned/leased to Shands

For shared COM/Shands hires only - together with % assigned/leased to UFCOM should not be greater than 100%.

Employment FTE % *

Percentage of provider’s employment/appointment, populated based on a 40 hour work week, converted into a decimal (e.g., 50% is .50).

Clinical FTE % *

Percentage of provider’s employment/appointment dedicated to clinical services, populated based on a 40 hour work week, converted into a decimal (e.g., if the provider is part time employment at .50 and she/he spends all of her/his employment delivering clinical services, the provider’s clinical FTE % should be .50 as well).

Out-of-State Clinical Exposures *

• Yes
• No

The delivery of professional healthcare services to patients located outside of the state of Florida.

Estimated # of hours annually dedicated to this service *

For Out-of-State Clinical providers only

List States Serviced *

For Out-of-State Clinical providers only

List the name(s) of the facility/facilities and full address where out-of-state services are being delivered *

For Out-of-State Clinical providers only

Telemedicine *

• Yes
• No

The practice of health care delivery by a practitioner who is located at a site other than the site where a recipient is located for the purposes of evaluation, diagnosis, or treatment.

List States Serviced *

For Telemedicine providers only

List the name(s) of the facility/facilities from which the provider will be providing the telemedicine services *

For Telemedicine providers only

Describe the telemedicine services that will be provided *

For Telemedicine providers only

Provider Practice Sites

List the name(s) of the facility/facilities and full address(es) where services are being delivered *

Comments/Additional Information regarding provider

File Upload

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