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.



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

Submitted By

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

Provider Details

Please refer to the FMMJUA Specialty Descriptions included above.
Example: ME, DO, APRN
Full license # including prefix, (e.g. ME012345)
Examples: College of Medicine, Student Health Services, or Shands.
Percentage of provider’s employment/appointment, populated based on a 40 hour work week, converted into a decimal (e.g., 50% is .50).
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).
The delivery of professional healthcare services to patients located outside of the state of Florida.
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.

Provider Practice Sites

Click or drag files to this area to upload. You can upload up to 10 files.