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, 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

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.