New Clinical Provider Submission Form

Requests to ADD NEW 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.  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 onboarding processes.

If you need to add more than 10 new providers, 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.

PLEASE NOTE:

• “Providers” (employees or volunteers) are those who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.
• Click on the following link for FMMJUA Specialty Descriptions to help complete the below questionnaire: FMMJUA Specialty Descriptions 
• 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 Shands Hospitals)UF Jacksonville (includes Shands HospitalsFSUUCFFAUFIU

ADDITION SUBMITTED BY ……

Submitter 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 Code *Please SelectEmployeeVolunteerOther

Work Email

Personal Email

Cell Phone

Work Phone

Position Title

Clinical/Specialty Description *

Please refer to the FMMJUA Specialty Descriptions included above.

Healthcare Degree

Example: ME, DO, APRN

Healthcare 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 UF COM/Shands hires only – together with % assigned/leased to Shands should not be greater than 100%.

% assigned/leased to Shands

For shared UF 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 %0.000.501.00

Select from one of the following three choices the percentage of the “Employment FTE %” (referenced above) dedicated to clinical/patient care and/or research: • 0.00 (0%): None of the provider’s employment/agency is dedicated to clinical/patient care and/or research. • 0.50 (50%): 1-50% of the provider’s employment/agency is dedicated to clinical/patient care and/or research. • 1.00 (100%): Over 50% of the provider’s employment/agency is dedicated to clinical/patient care and/or research.

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

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

Submit