The California Participating Practitioner form is a document required for healthcare professionals applying for participation in certain healthcare organizations. This form collects essential information regarding any professional liability lawsuits or arbitrations involving the practitioner within the past seven years. Completing this form accurately is crucial for a smooth application process.
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The California Participating Practitioner form is an essential document for healthcare providers seeking to participate in various healthcare organizations. This form requires practitioners to disclose any professional liability lawsuits or arbitration actions that have occurred within the past seven years. It aims to gather comprehensive information about each case, including the patient’s details, the nature of the allegations, and the outcomes of the lawsuits. Practitioners must answer all questions thoroughly to prevent delays in the application process. If there are multiple cases, additional copies of the form must be completed for each one. The form also includes sections for identifying information, case details, and a summary of the circumstances surrounding each action. Importantly, practitioners must certify the accuracy of the information provided and authorize the release of their malpractice claims history for credentialing purposes. This process ensures that healthcare organizations can evaluate a practitioner's qualifications and history effectively.
California Participating Practitioner Application
Addendum B
Professional Liability Action Explained
This Addendum is submitted to
herein, this Healthcare Organization
Please complete this form for each pending, settled or otherwise conclude professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past seven (7) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by any insurer, company, hospital or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one professional liability lawsuit or arbitration action, please photocopy this Addendum B prior to completing, and complete a separate form for each lawsuit.
Please check here if there are no pending/settled claims to report (and sign below to attest).
I. Practioner Identifying Information
Last Name:
First Name:
Middle:
II. Case Information
Patient's Name:
City, County, State where lawsuit filed:
Patient Gender
Male
Female
Patient DOB:
Court Case number, if known:
Date of alleged incident serving as Date suit filed:
basis for the
lawsuit/
arbitration:
Location of incident:
Hospital
My Office
Other doctor's office
Surgery Center
Other (specify)
Relationship to patient (Attending physician, Surgeon, Assistant, Consultant, etc.)
Allegation
Is/was there an insurance company or other liability protection company or
organization providing coverage/defense of the lawsuit or arbitration action?
Yes
No
If yes, please provide company name, contact person, phone number, location and carrier's claim identification number, or other liability protection company or organization.
If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s). Please fax this document to your attorney as this will serve as your authorization:
Name:
Telephone Number:
Fax Number:
California Participating Physician Application - ADDENDUM A
1
Version 1.2012
III. Status of Lawsuit/Arbitration (check one)
Lawsuit/arbitration still ongoing, unresolved.
Judgment rendered and payment was made on my behalf.
Amount paid on my behalf:
Judgment rendered and I was found not liable.
Lawsuit/arbitration settled and payment made on my behalf.
Lawsuit/arbitration settled/dismissed, no judgment rendered, no payment made on my behalf.
$
Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheets.
Please include:
1.Condition and diagnosis at the time of incident,
2.Dates and description of treatment rendered, and
3.Condition of patient subsequent to treatment.
SUMMARY
I certify that the information in this document and any attached documents is true and correct. I agree that “this Healthcare Organization”, its representatives, and any individuals or entities providing information to this Healthcare Organization in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document, which is part of the California Participating Practitioner Application. In order for the participating healthcare organizations to evaluate my application for participation in and/or my continued participation in those organizations, I hereby give permission to release to this Healthcare Organization about my medical malpractice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorney(s) listed on Page 1 to discuss any information regarding this case with “this Healthcare Organization”.
APPLICANT SIGNATURE (Stamp is Not Acceptable)
PRINTED NAME
DATE
California Participating Practitioner Application - ADDENDUM B
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Completing the California Participating Practitioner form is a crucial step in the credentialing process. This form requires detailed information about any professional liability actions you may have faced in the past seven years. It is important to provide accurate and comprehensive responses to ensure a smooth review of your application.
What is the purpose of the California Participating Practitioner form?
The California Participating Practitioner form serves as a comprehensive application for healthcare professionals seeking to participate in specific healthcare organizations. It requires detailed information about the practitioner's professional liability history, including any pending or settled lawsuits or arbitration actions from the past seven years. This information is crucial for the organizations to assess the practitioner's qualifications and ensure patient safety. By collecting this data, the form helps maintain high standards within the healthcare system and supports informed decision-making regarding practitioner participation.
What information must be provided about pending or settled lawsuits?
When filling out the form, practitioners must provide detailed information about each pending or settled lawsuit or arbitration action. This includes the patient's name, the location where the lawsuit was filed, the nature of the allegations, and the relationship of the practitioner to the patient. Additionally, practitioners must indicate whether an insurance company provided coverage during the lawsuit and supply relevant contact information for that insurer. If there are multiple lawsuits, a separate form must be completed for each one to ensure clarity and thoroughness in the application process.
What happens if a practitioner has no pending or settled claims to report?
If a practitioner has no pending or settled claims to report, they can simply check the designated box on the form indicating this status. However, it is essential that they still sign the form to attest to the accuracy of their statement. This step is vital, as it confirms that the information provided is complete and truthful, which helps expedite the application process without unnecessary delays.
How is the information in the form used by healthcare organizations?
The information collected through the California Participating Practitioner form is used by healthcare organizations to evaluate the qualifications of practitioners seeking participation. It allows these organizations to conduct thorough credentialing and peer review processes. The data helps them assess the practitioner's professional history, particularly regarding any malpractice claims. Importantly, the confidentiality of the information is maintained, and it is shared only within the context of legitimate credentialing activities. This ensures that patient safety and care quality remain top priorities in the healthcare environment.
Filling out the California Participating Practitioner form can be a straightforward process, but several common mistakes can lead to delays or complications. One of the most frequent errors is failing to provide complete information. Each section of the form requires specific details, and skipping any part can result in the application being delayed. It's crucial to read each question carefully and ensure that all fields are filled out thoroughly.
Another common mistake is misunderstanding the requirement to report all professional liability actions. Applicants sometimes overlook the need to include settled cases or those that have concluded. Even if a case did not result in a payment, it must still be reported. Failing to disclose this information can raise red flags during the review process.
Many applicants also struggle with the section regarding the relationship to the patient. It’s essential to accurately describe your role, whether you were the attending physician, surgeon, or in another capacity. Misclassifying your relationship can lead to confusion and may affect the evaluation of your application.
In addition, providing vague or incomplete summaries of the circumstances surrounding the lawsuit is a frequent issue. The form requests a detailed narrative, including the patient's condition and treatment. Offering insufficient detail can hinder the healthcare organization’s ability to assess the situation properly.
Another mistake involves the handling of insurance information. Applicants may forget to include the necessary details about their liability coverage, such as the insurance company’s name and contact information. This information is vital for the organization to verify your coverage and understand the context of the claims.
Moreover, some individuals neglect to check the box indicating that there are no pending or settled claims when applicable. This oversight can lead to unnecessary follow-up questions and prolong the application process. If there are no claims to report, it’s essential to make that clear right from the start.
Another point of confusion often arises in the section where the applicant must indicate the status of the lawsuit or arbitration. Misunderstanding the options can lead to selecting the wrong status, which may misrepresent the situation and complicate the review process.
Finally, many applicants fail to sign and date the form appropriately. A missing signature can invalidate the application, causing further delays. Always double-check that your signature is present and that the date is filled in correctly before submitting the form.
The California Participating Practitioner form is an essential document for healthcare providers wishing to participate in certain healthcare organizations. Along with this form, several other documents are commonly required to ensure a comprehensive evaluation of a practitioner's qualifications and history. Below is a list of these forms, each serving a specific purpose in the application process.
Each of these documents plays a vital role in the overall credentialing process. They help ensure that healthcare practitioners meet the necessary standards to provide safe and effective care to patients. Completing these forms accurately and thoroughly can significantly expedite the application process.
When filling out the California Participating Practitioner form, there are important guidelines to follow. Here are six things to do and not do:
Here are some common misconceptions about the California Participating Practitioner form:
When filling out the California Participating Practitioner form, keep the following key points in mind: