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, 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

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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