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The New Jersey Universal Physician Application is a comprehensive form designed for physicians in New Jersey. It gathers personal, educational, and professional details, including work history, hospital privileges, and insurance information, essential for various administrative and regulatory purposes. This form streamlines the process of reporting accurate and updated information for physicians practicing or intending to practice in the state.

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Content Overview

The New Jersey Universal Physician Application form serves multiple purposes, seeking to consolidate various pieces of information that are essential for physicians practicing or intending to practice in the state. This comprehensive form starts with the physician's personal information including name, professional degrees, and other identifiers, before moving on to practice location information which details service type and practice names intended for directory listing. A significant portion of the form is dedicated to licenses, certifications, and identification numbers, outlining the requirements for practicing in various states, as well as information on DEA and CDS registrations, vital for those prescribing medication. Education and training history play a crucial role, spotlighting where and what levels of medical education and postgraduate training the physician has attained, including any additional graduate-level education that might influence their practice. Moreover, the form delves into professional or medical specialty information, asking about board certifications and hospital affiliations, which sheds light on the physician's qualifications and areas of permission to admit and treat patients in hospitals. This attention to detail provides a snapshot of a physician's credentials, ensuring they meet New Jersey's standards for medical practice. Additionally, the form requests a detailed work history, professional references, and information regarding professional liability insurance coverage, highlighting the state's thorough approach in gathering a physician's professional background. It also includes questions about the physician's status or role in practice and any interests in outside clinical labs, aiming to gather comprehensive information relevant to their professional endeavors in New Jersey.

Document Sample

New Jersey Universal Physician Application

(Please type or print)

SECTION 1

Personal Information

Physician Name (Last)		(First)	(MI) (Jr., Sr., etc.)	Professional Degree(s) (MD, DO,		Social Security Number
				DDS, DMD, DPM, DC)

Other Name Used			Years Associated with	Other Name Used			Years Associated with
			Former Name				Former Name

Date of Birth (mm/dd/yyyy)			Gender		Are you eligible to work in the United States?
/	/		Male	Female		Yes	No

Home Mailing Address				City		State	Zip Code

Practice Location Information

Type of Service Provided
	Primary Care Specialist			Non-Primary Care Specialist

Physician Group Name/Practice Name (to appear in the directory)				Group/Corporate Name (as it appears on W-9), if different from Group
				Name/Practice Name

Primary Office Mailing Address				City		State	Zip Code

Primary Office Telephone No.		Primary Office Fax No.			Primary Office E-mail Address

Tax ID Number and Associated Individual Group Number and Name for This Location

Are you currently practicing at the above location?				If No, what is your expected start date?
Yes	No

Other Office Street Address				City		State	Zip Code

Telephone No.		Fax No.			E-mail Address

Do you want this site listed in the Directory?			Tax ID Number and Associated Individual Group Number and Name for This Location
Yes	No

Other Office Street Address				City		State	Zip Code

Telephone No.		Fax No.			E-mail Address

Do you want this site listed in the Directory?			Tax ID Number and Associated Individual Group Number and Name for This Location
Yes	No

Correspondence Office Street Address				City		State	Zip Code

Telephone No.		Fax No.			E-mail Address

If you have additional offices, please submit an attachment containing the above information and check this box:

MC-5
DEC 05	Page 1 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

License and Other Identification Numbers

(License Information - Include all license(s) and certifications in all States where you are currently or have previously been licensed.)

Type

State(s) of

Do You Currently

License/Certificate

Expiration

N/A

Registration

Practice In This State?

Number

Date

License

Yes

License

Yes

DEA Registration Certificate

Yes

CDS Registration Certificate

Yes

Other (CDS/DEA) (Specify)

Yes

UPIN

National Provider ID

Are you a participating

Medicare Provider No.

Are you a participating

Medicaid Provider No.

(when available)

Medicare Provider?

Medicaid Provider?

International Medical Graduates: Are you certified by the Educational

If yes, ECFMG Number

ECFMG Issue Date

Council for Foreign Medical Graduates (ECFMG)?

Yes

Medical Education

School Issuing Professional Degree (Medical, Dental, Chiropractic)

Degree

Attendance Dates

Address

City

State/Country

Zip Code

If you have attended additional schools, please submit an attachment containing the above information and check this box:

Post-Graduate Education		Institution Name
Internship	Fellowship
Residency	Teaching Appointment

Address		City	State	Zip Code

Specialty		Start Date (Month/Year)	End Date (Month/Year)

Post-Graduate Education		Institution Name
Internship	Fellowship
Residency	Teaching Appointment

Address		City	State	Zip Code

Specialty		Start Date (Month/Year)	End Date (Month/Year)

Post-Graduate Education		Institution Name
Internship	Fellowship
Residency	Teaching Appointment

Address		City	State	Zip Code

Specialty		Start Date (Month/Year)	End Date (Month/Year)

If you completed additional training, please submit an attachment containing the above information and check this box:

Other Graduate Level Education for Which a Degree Was Obtained -	Institution Name
Type of Program (Psychology, Public Health, MBA, etc.)

Address	City		State	Zip Code

Degree Obtained		Date of Graduation (Month/Year)

MC-5
DEC 05	Page 2 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Professional/Medical Specialty Information

Primary Specialty			Board Certified?			Name of Certifying Board
			Yes		No

Initial Certification Date			Recertification Date (s) (if applicable)				Expiration Date (if applicable)

Do you wish to be listed in the directory under this specialty?				If not Board Certified, indicate any of the following that apply:
HMO	Yes	No			I have taken exam, results pending for:			(board)
PPO	Yes	No			I am intending to sit for the Boards on:			(date)
POS	Yes	No			I am not planning to take the Boards.

Secondary Specialty			Board Certified?			Name of Certifying Board
			Yes		No

Initial Certification Date			Recertification Date (s) (if applicable)				Expiration Date (if applicable)

Do you wish to be listed in the directory under this specialty?				If not Board Certified, indicate any of the following that apply:
HMO	Yes	No			I have taken exam, results pending for:			(board)
PPO	Yes	No			I am intending to sit for the Boards on:			(date)
POS	Yes	No			I am not planning to take the Boards.

Additional Specialty			Board Certified?			Name of Certifying Board
			Yes		No

Initial Certification Date			Recertification Date (s) (if applicable)				Expiration Date (if applicable)

Do you wish to be listed in the directory under this specialty?				If not Board Certified, indicate any of the following that apply:
HMO	Yes	No			I have taken exam, results pending for:			(board)
PPO	Yes	No			I am intending to sit for the Boards on:			(date)
POS	Yes	No			I am not planning to take the Boards.

List Additional Areas of Professional Practice, Interest or Focus (HIV/AIDS, etc.)

Hospital Affiliations and Privileges

Do you have hospital privileges?		If you do not admit patients, what admitting arrangements do you have?

Yes	No

If you have privileges, please complete the section below. Include all hospitals where you have privileges.

Primary Hospital where you have Admitting Privileges					Telephone Number

Address			City				State	Zip Code

Full Unrestricted Privileges		Type of Privileges	Are Privileges Temporary?			Of the total admissions to all hospitals in the
Yes	No		Yes	No		past year, what percentage is to this specific
Yes	No		Yes	No
						hospital?
Other Hospital Where you Have Privileges					Telephone Number

Address			City				State	Zip Code

Full Unrestricted Privileges		Type of Privileges	Are Privileges Temporary?			Of the total admissions to all hospitals in the
Yes	No		Yes	No		past year, what percentage is to this specific
Yes	No		Yes	No
						hospital?
Other Hospital Where you Have Privileges					Telephone Number

Address			City				State	Zip Code

Full Unrestricted Privileges		Type of Privileges	Are Privileges Temporary?			Of the total admissions to all hospitals in the
Yes	No		Yes	No		past year, what percentage is to this specific
Yes	No		Yes	No
						hospital?
Additional Hospital Where you Have Privileges					Telephone Number

Address			City				State	Zip Code

Full Unrestricted Privileges		Type of Privileges	Are Privileges Temporary?			Of the total admissions to all hospitals in the
Yes	No		Yes	No		past year, what percentage is to this specific
Yes	No		Yes	No
						hospital?

If you have additional hospital affiliations, please submit an attachment containing the above information and check this box:

MC-5
DEC 05	Page 3 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

List all other hospitals where you have previously had privileges.

Hospital Name

Dates of Affiliation

Address

City

State

Zip Code

Hospital Name

Dates of Affiliation

Address

City

State

Zip Code

If you have other previous hospital affiliations, please submit an attachment containing the above information and check this box:

Work History

Include chronological work history since completion of training.

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

Practice/Employer Name

Start Date/End Date

Address

City

State

Zip Code

For additional work history, please submit an attachment containing the above information and check this box:

Please provide an explanation of any gaps greater than six months in each work history.

Date

Explanation

Date

Explanation

Are you currently on active military duty or on military reserve?

Yes

References

Please provide three professional references that are not partners in your own group practice and are not relatives.

Name

Street Address

City, State, Zip Code

MC-5
DEC 05	Page 4 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Professional Liability Insurance Coverage

Are you self-insured?
	Yes	No

Name of Current Malpractice Insurance Carrier or Self-Insured Entity				Telephone Number	Effective Date			Expiration Date

Address				City			State	Zip Code

Policy Number	Amount of Coverage per Occurrence		Amount of Coverage Aggregate			Type of Coverage		Length of Time with
						Individual		Carrier
						Shared
Name of Previous Malpractice Insurance Carrier or Self-Insured Entity				Telephone Number	Effective Date			Expiration Date

Address				City			State	Zip Code

Policy Number	Amount of Coverage per Occurrence		Amount of Coverage Aggregate			Type of Coverage		Length of Time with
						Individual		Carrier
						Shared

Status/Role in Practice

Owner

Partner

Employee

Officer

Shareholder

Interests in Outside Clinical Lab(s)

If you own/co-own, or have interests in any other outside clinical lab, please fill in below:

Legal Billing Name	TIN (Attach copy of W-9)	Clinical Description

Please provide a summary pattern for this business:

Office Coverage
List names of colleague(s) providing regular coverage and his/her specialty(ies).
Name		Provider Specialty





Partners
List full names of all partners in your practice (attach list for large group).
Name (Last, First, MI)		Name (Last, First, MI)

MC-5
DEC 05	Page 5 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

Site 1

Site 2

Office Address:

Type of Practice:

Solo

Single Specialty Group

Multi-Specialty Group

Solo

Single Specialty Group

Multi-Specialty Group

Office Manager or Business Office Staff Contact::

Name:

Telephone No.:

Fax No.:

Credentialing Contact (if different from above):

Name:

Telephone No.:

Fax No.:

E-mail:

Address:

City:

State:

Zip:

State:

Zip:

Billing Information:

Billing Rep. Name:

Address:

City:

State:

Zip:

State:

Zip:

Telephone No.:

Fax No.:

E-mail:

Dept. Name if Hosp.-Based:

Check should be payable to

Do you have capability of electronic billing?

Yes

Do you have capability of electronic billing?

Yes

Office Business Hours (hours patients are seen):

Day

Office

Morning

Afternoon

Evening

Day

Office

Morning

Afternoon

Evening

Hours

MON

TUES

WED

THUR

FRI

SAT

SUN

After hours, back office phone number

for health plan business use only:

Do you provide 24 hour/7 day a

week phone coverage for this site?

Yes

week phone coverage for this site?

Yes

If yes, indicate type:

Answering service

Voice mail with instructions to call answering service

Voice mail with other instructions

(Continue on next page.)

MC-5
DEC 05	Page 6 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

(Continued from previous page.)

Site 1, Continued

Site 2, Continued

Do you accept new patients into the practice?

Yes

Do you accept new patients into the practice?

Yes

-All new patients?

Yes

-All new patients?

Yes

-Existing patients with change of payor?

Yes

-Existing patients with change of payor?

Yes

-New patients from physician referral?

Yes

-New patients from physician referral?

Yes

-New Medicare patients?

Yes

-New Medicare patients?

Yes

-New Medicaid patients?

Yes

-New Medicaid patients?

Yes

If this information varies by health plan, provide explanation:

Are there any practice limitations?

Yes

Are there any practice limitations?

Yes

If yes, indicate limitations below:

Gender:

Male Only

Female Only

N/A

Gender:

Male Only

Female Only

N/A

Patient Age Limitation (List Ages):

N/A

Patient Age Limitation (List Ages):

N/A

List Other Limitations:

Do mid-level practitioners such as nurse

practitioners, physician assistants, midwives,

social workers or other non-physician providers

care for patients in your practice?

Yes

care for patients in your practice?

Yes

If yes, provide the following information for each staff member:

If yes, indicate limitations below:

Name:

Professional Designation:

State License Number:

Name:

Professional Designation:

State License Number:

Please attach a list of any additional mid-level practitioners.

Non-English Languages spoken:

by health care professional:

by office personnel:

Are interpreters available?

Yes

Are interpreters available?

Yes

If yes, specify languages:

Does this office meet ADA

accessibility standards?

Yes

accessibility standards?

Yes

Does this site provide handicapped accessibility for each of the

following:

Building

Yes

Building

Yes

Parking

Yes

Parking

Yes

Restroom

Yes

Restroom

Yes

Other:

Does this site have other services for the disabled?

Yes

If yes, indicate type:

Text Telephony - TTY

Yes

Text Telephony - TTY

Yes

American Sign Language-ASL

Yes

American Sign Language-ASL

Yes

Mental/Physical Impairment Services

Yes

Mental/Physical Impairment Services

Yes

Other:

(Continue on next page.)

MC-5
DEC 05	Page 7 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Other Practice Information (specify for each site)

(Continued from previous page.)

Site 1, Continued

Site 2, Continued

Is this site accessible by public transportation?

Yes

Bus

Yes

Bus

Yes

Subway

Yes

Subway

Yes

Regional Train

Yes

Regional Train

Yes

Other:

Does this site provide childcare services?

Yes

Does this site provide childcare services?

Yes

Does this office qualify

as a minority business enterprise?

Yes

as a minority business enterprise?

Yes

Do you or does someone in your office have the following

certifications? (Indicate for each office location.)

Yes

No Exp.Date

Yes

No Exp.Date

BLS (Basic Life Support)

ACLS (Advanced Cardiac Life Support)

ALSO (Advanced Life Support in OB)

PALS (Pediatric Advanced Life Support)

ATLS (Advanced Trauma Life Support)

NALS (Neonatal Advanced Life Support)

CPR (Cardio-Pulmonary Resuscitation)

Does your site provide any of the following services on site?

(Indicate for each office location.)

Laboratory Services

Yes

Laboratory Services

Yes

Certificate of Participation from CLIA or

another accrediting/certifying program

[AAFP, COLA, CAP, Medical Laboratory

Evaluation (MLE)] Program

Yes

Evaluation (MLE)] Program

Yes

If yes, list program:

Radiology Services

Yes

Radiology Services

Yes

X-Ray Certification

Yes

X-Ray Certification

Yes

If yes, include type:

EKG’s

Yes

EKG’s

Yes

Care of Minor Lacerations

Yes

Care of Minor Lacerations

Yes

Pulmonary Function Testing

Yes

Pulmonary Function Testing

Yes

Allergy Injections

Yes

Allergy Injections

Yes

Allergy Skin Testing

Yes

Allergy Skin Testing

Yes

Office Gynecology (Routine Pelvic/Pap)

Yes

Office Gynecology (Routine Pelvic/Pap)

Yes

Drawing Blood

Yes

Drawing Blood

Yes

Age Appropriate Immunizations

Yes

Age Appropriate Immunizations

Yes

Flexible Sigmoidoscopy

Yes

Flexible Sigmoidoscopy

Yes

Tympanometry/Audiometry Screening

Yes

Tympanometry/Audiometry Screening

Yes

Asthma Treatment

Yes

Asthma Treatment

Yes

Osteopathic Manipulation

Yes

Osteopathic Manipulation

Yes

IV Hydration/Treatment

Yes

IV Hydration/Treatment

Yes

Cardiac Stress Tests

Yes

Cardiac Stress Tests

Yes

Physical Therapy

Yes

Physical Therapy

Yes

Additional Office Procedures Provided (incl. surgical procedures)

Is anesthesia administered in your office?

Yes

Is anesthesia administered in your office?

Yes

If Yes, what class or category of anesthesia do you use?

Who administers it?

For additional office sites, please submit an attachment containing the above information and check this box:

MC-5
DEC 05	Page 8 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

Patient Scheduling

What is patient wait time for emergency care? .................................................

What is patient wait time for urgent care?.........................................................

What is patient wait time for symptomatic care?...............................................

What is patient wait time for scheduling routine visits? .....................................

What is patient wait time for scheduling routine care? ......................................

What is average wait time for patients between waiting room and examination?

What is average wait time in minutes for returning a patient’s call?..................

Required Attachments or Supplemental Information

Please attach hard copy or scanned documents of the following:

♦Copy(ies) of DEA registration certificate(s)

♦Copy of state Controlled Dangerous Substance (CDS) registration certificate(s)

♦Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and provider’s name

♦Copy(ies) of W-9(s) for verification of each tax identification number used

♦Copy of workers compensation certificate of coverage, if applicable

SECTION 2 - DISCLOSURE QUESTIONS

Please answer each question and include an explanation for any question answered “Yes.”

Licensure

1.Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation or have you ever been subject to

a consent order, probation or any conditions or limitations by any state licensing board?...................

2.Have you ever received a reprimand or been fined by any state licensing board?..............................

Yes

No No

Hospital Privileges and Other Affiliations

3.Have your clinical privileges at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board? ..........................................................................................................

4.Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?.............................................................................................................................

5.Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? .....................................................................

Yes

Education, Training and Board Certification

6.Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? .....................................................

7.Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship,

or other clinical education program?....................................................................................................

8.Have any of your board certifications or eligibility ever been revoked? ...............................................

9.Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? ...................................................................................................................

Yes

No No

MC-5
DEC 05	Page 9 of 14 Pages.

NEW JERSEY UNIVERSAL PHYSICIAN APPLICATION (Continued)

DEA or CDS Certification/Authorization

10.Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s)

or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or
voluntarily relinquished?	Yes	No

Medicare, Medicaid or Other Governmental Program Participation

11.Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified, subject to a recovery action or otherwise restricted in

regard to participation in the Medicare or Medicaid program, or in regard to other federal or
state governmental health care plans or programs?	Yes	No

Other Sanctions or Investigations

12.Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare

or Medicaid program, or any other private, federal or state health program? ......................................

13.To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?.........................................

14.Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? ....................................................................................................

15.Has a patient, employee, or co-worker ever accused you of sexual harassment or other illegal misconduct that resulted in an investigation, sanction or other formal action? ..........................

16.Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by

a hospital or healthcare facility of any military agency? .......................................................................

Yes

Professional Liability Insurance Information and Claims History

17.Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? ........................................................

18.Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by

your professional liability insurance carrier, based on your individual liability history? ........................

Yes

Malpractice Claims History

19.Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated or litigated)? If yes, provide information for each case on the attached form located

at the end of the Disclosure questions (list all separately)...................................................................

For any malpractice actions, please complete addendum and check this box:

Yes

Criminal/Civil History

(Note: A criminal record will not necessarily be a bar to acceptance. Decisions will be made by each health plan or credentialing organization based upon all relevant circumstances, including the nature of the crime.)

20.Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional? ...............

21.Have you ever been arrested, charged or indicted for, convicted of, pled guilty to, or pled nolo contendere to any felony, crime or other offense in the last ten years or been found liable or responsible for or been named as a defendant in any civil offense that alleged fraud,

an act of violence, child abuse or a sexual offense or sexual misconduct?.........................................

22.Have you ever been court-martialed for actions related to your duties as a medical professional? .......................................................................................................................................

Yes

MC-5
DEC 05	Page 10 of 14 Pages.

↓ Nj Universal Physician Application PDF Form

Form Attributes

Fact Name	Description
Form Purpose	The New Jersey Universal Physician Application is designed for physicians to provide comprehensive personal and professional information for various administrative purposes such as credentialing and employment.
Sections Covered	It includes sections on personal information, practice location, license and identification numbers, education, professional/medical specialty, hospital affiliations, work history, professional references, liability insurance coverage, and interests in outside clinical labs.
Detail Level	This form requires detailed responses, including previous work history, education, and affiliations, to thoroughly assess the physician's professional background.
Additional Documentation	Physicians are prompted to attach additional documentation for education, training, hospital affiliations, and work history if the space provided on the form is insufficient.
Educational and Professional Credentials	Applicants must disclose their educational background, including graduate and post-graduate education, alongside their professional credentials such as board certifications and licenses.
Governing Law	This form is specifically tailored to meet the compliance requirements and standards set forth by New Jersey state laws pertaining to the medical profession.

Nj Universal Physician Application: Usage Guide

Completing the New Jersey Universal Physician Application form is a crucial step for physicians seeking to work within the state. It's designed to provide a comprehensive profile of your professional credentials, education background, and practice information. To ensure a smooth process, it's vital to furnish accurate and complete information in every section of the application.

Steps to Fill Out the Form:

Begin with SECTION 1: Personal Information: Enter your full name, including any suffixes (Jr., Sr., etc.), professional degrees, social security number, any other names used, date of birth, gender, and eligibility to work in the U.S.
Fill in your Home Mailing Address, including city, state, and zip code.
Under Practice Location Information, specify the type of service provided, the name of your physician group/practice, primary office address, contact information, and tax ID number. Also, indicate if you are currently practicing at the mentioned location.
If applicable, provide details about other office locations, including whether each site should be listed in the Directory.
In the License and Other Identification Numbers section, list all your professional licenses, DEA and CDS registration certificates, UPIN, and National Provider ID.
Detail your Medical Education and any additional education, including institutions, degrees, and dates.
Outline your Post-Graduate Education, including internships, fellowships, and residencies, with relevant details for each.
Specify your Professional/Medical Specialty Information, including board certifications and specialties.
For Hospital Affiliations and Privileges, list all hospitals where you have privileges, specifying the type and if they are temporary.
Provide a complete Work History since the completion of your training, noting any gaps over six months.
List three professional References that meet the specified criteria.
Detail your Professional Liability Insurance Coverage, including carrier information, coverage amounts, and policy details.
Fill in your Status/Role in Practice and any interests in Outside Clinical Labs.
Under Office Coverage, list names and specialties of colleagues providing regular coverage.
If part of a large group, attach a list of all Partners in your practice.

Once you've carefully reviewed and completed each section of the New Jersey Universal Physician Application, verify that all information is correct and comprehensive. Missing or inaccurate information can delay the process. After completing the form, sign and date the last page to certify the accuracy of the information provided. Your next steps will involve submitting the completed form to the designated state department or board, along with any required fees and additional documentation they may request.

Listed Questions and Answers

What is the New Jersey Universal Physician Application?

The New Jersey Universal Physician Application is a detailed form that doctors fill out to provide their personal and professional information. This form is used for various purposes, including job applications, hospital privileges applications, and insurance credentialing. It requires physicians to disclose their education, training, work history, hospital affiliations, and more.

Who needs to complete the New Jersey Universal Physician Application?

Any physician who is applying for medical licensure, hospital privileges, or wants to practice medicine in the state of New Jersey may need to complete this application. It is also used by physicians seeking to update their credentials or apply for new positions within the healthcare field in New Jersey.

What information do I need to provide in the application?

The application requires a wide range of information, including:

Personal information such as your name, date of birth, and Social Security number
Professional degrees and any other names used
Details about your current practice and any other office locations
License and certification information for New Jersey and any other states
Medical education and post-graduate education details
Board certification information
Hospital affiliations and work history
Professional liability insurance coverage
References

How do I submit the application?

After completing the application, you should submit it to the relevant organization or body that has requested it. This could be a hospital credentialing department, a medical licensing board, or an insurance company. Check the specific submission instructions provided by the organization to ensure proper delivery.

Is it mandatory to fill out every section of the application?

Yes, it's important to fill out every section of the application to the best of your ability. Missing information can delay the processing of your application. If a section does not apply to you, indicate this by writing "N/A" (not applicable) in the space provided.

What if I have additional locations or details that don't fit in the provided space?

If you have more information than the form allows (such as additional office locations, hospital affiliations, or work history), you should attach a separate sheet listing these details. There's a checkbox on various sections of the form to indicate that you've included attachments.

How can I make corrections if I make a mistake on the application?

If you make a mistake, it's recommended to start with a fresh application if you haven't submitted it yet. If the application has already been submitted, contact the organization to which you submitted the form and ask for guidance on how to make corrections. They might require a written explanation or a new form, depending on the error.

Do I need to provide references?

Yes, the application requires you to provide three professional references. These references should not be partners in your practice and should not be related to you. Be sure to notify your references beforehand, as they may be contacted for verification.

What happens after I submit my application?

After you submit your application, it will be reviewed by the receiving organization. This process can take some time, so be prepared to wait. You may be contacted for additional information or clarification. Once your application has been processed, you will be notified of the next steps or any further requirements.

Common mistakes

When filling out the New Jersey Universal Physician Application form, attention to detail is crucial. However, some common mistakes can occur during the process. Identifying and avoiding these errors can lead to a smoother application process.

Not checking if all sections are complete: Every part of the form needs to be filled out. Sometimes, sections that are not applicable are skipped instead of being marked as "N/A" for not applicable. This oversight can make it appear as though the form is incomplete.
Using different names without explanation: If applicants have used other names in the past, it is essential to list those names and the years they were used. Forgetting to explain name changes can lead to questions about the applicant's identity.
Incorrect or missing license information: License numbers, states of issuance, expiration dates, and other crucial details must be accurate. Missing or incorrect information can delay the verification process.
Misrepresenting board certification status: Applicants need to be clear about their board certification status. Indicating the wrong status or leaving this section incomplete can mislead reviewers.
Failing to list all work history or gaps in work history: The application requires a complete work history since the completion of training. Neglecting to provide this information or not explaining gaps greater than six months can raise concerns.
Inadequate reference information: Providing professional references who are not partners or relatives and ensuring their contact information is complete and accurate is essential. Missing or incomplete information can delay the review process.

To avoid these common mistakes, applicants should thoroughly review the entire form before submission, ensure all sections are filled correctly, and provide clear and accurate information throughout.

Documents used along the form

When submitting the New Jersey Universal Physician Application, it's essential to include all necessary documentation to ensure a comprehensive evaluation process. These documents often encompass a range of professional credentials, educational proofs, and legal certifications. The following are some of the forms and documents frequently used alongside this application:

Curriculum Vitae (CV): Provides a detailed overview of the physician's education, work history, publications, and any relevant professional activities.
Medical School Diploma: A copy of the original diploma verifying graduation from an accredited medical school.
Postgraduate Training Certifications: Documentation from completed internships, residencies, and fellowships, showing the extent and specialization of postgraduate medical training.
State Medical License(s): Copies of active medical licenses from New Jersey or any other state where the physician is licensed to practice.
Board Certification(s): Documentation from the appropriate certifying boards indicating the physician's specialty or specialties, and current board certification status.
Drug Enforcement Administration (DEA) Certificate: For physicians prescribing medication, a current DEA certificate is required.
Controlled Dangerous Substances (CDS) Certificate: If applicable, the New Jersey CDS certificate for prescribers of controlled substances within the state.
Basic Life Support (BLS) / Advanced Cardiovascular Life Support (ACLS) Certifications: Proof of current certification in life-saving procedures can be important, especially for emergency or critical care specialties.
Professional Liability Insurance Certificate: Evidence of current malpractice insurance coverage, including the carrier, policy number, and coverage amounts.
Reference Letters: Letters from colleagues or supervisors attesting to the physician's medical skills, ethics, and professional conduct. Typically, three letters are suggested.

Together with the New Jersey Universal Physician Application, these documents help in painting a complete picture of the applicant's qualifications and readiness to provide healthcare services. It's crucial to check with the New Jersey State Board of Medical Examiners or the specific healthcare institution for any additional requirements or updated forms.

Similar forms

The New Jersey Universal Physician Application form bears similarities to several other professional documentation processes due to its comprehensive nature and requirement for detailed personal and professional information. Comparable documents include the Medical License Application, Credentialing Application Forms used by healthcare systems, Curriculum Vitae (CV), and the Professional Liability Insurance Application. Each of these forms serves a distinct purpose in the professional landscape of healthcare but parallels the Universal Physician Application in the depth and breadth of information collected.

The Medical License Application, utilized by physicians seeking licensure to practice medicine in a given state, shares close resemblance to the Universal Physician Application in requiring detailed educational background, licensure information, and work history. Although aimed at obtaining a license rather than applying for provider status, this form demands an extensive account of a physician's credentials, professional journey, and legal standing in the medical field, much like the information required on the Universal Application.

Credentialing Application Forms, used by hospitals and healthcare systems to verify the qualifications of their healthcare providers, also mirror the Universal Physician Application. These forms meticulously review a physician’s education, training, board certification, work history, and professional references to ensure competence and credibility. Similarly, the Universal Physician Application gathers substantial information to establish a physician's eligibility and qualifications for practice within New Jersey, highlighting both documents' roles in maintaining high standards of healthcare provision.

Another document exhibiting notable similarity to the Universal Physician Application is the Curriculum Vitae (CV) of a physician. A CV is more than a career summary—it is a detailed record of professional experiences, educational achievements, publications, awards, and other relevant professional activities. Like the Universal Application, a physician’s CV is a comprehensive document that outlines their professional identity, though in a less standardized format.

The Professional Liability Insurance Application is another document echoing the thoroughness of the Universal Physician Application. This form requires detailed information about a physician’s practice, including work history, types of procedures performed, and information on any previous claims or legal actions taken against them. It ensures that the physician is accurately assessed for risk before being offered liability coverage. Both forms play crucial roles in protecting public safety and ensuring the integrity of the medical profession by requiring detailed disclosures about a physician’s background and professional conduct.

Dos and Don'ts

When filling out the New Jersey Universal Physician Application form, there are several dos and don'ts to consider for a smooth and accurate submission:

Do type or print clearly to ensure all information is legible.
Do check for any required attachments if you have additional information that does not fit in the provided spaces.
Do verify all dates (mm/dd/yyyy) are correctly entered, especially your date of birth, license expiration dates, and education completion dates.
Do ensure you accurately list all professional degrees and certifications, including state licenses and board certifications.
Do disclose any other names you have used professionally to avoid any discrepancies or confusion.
Do provide complete contact information for practice locations, including a primary email address and telephone numbers.
Do list all hospital affiliations, including the type of privileges held at each, accurately reflecting your current status.
Do detail your work history comprehensively, including explanations for any employment gaps longer than six months.
Do include the contact information for at least three professional references who are not partners or relatives.
Do carefully review all sections for completeness and accuracy before signing and dating the form.

And in contrast, here are some things to avoid:

Don't leave any sections blank unless they genuinely do not apply to you. In such cases, note it as "N/A" or "Not Applicable."
Don't provide outdated contact information or addresses; ensure all information is current and correct.
Don't forget to list all the states where you hold or have held medical licenses or certifications.
Don't skip the signature and date at the end of the application, as an unsigned application is often considered incomplete.
Don't provide incorrect or fabricated information, as this can lead to application denial or legal consequences.
Don't neglect to attach additional documents if you ran out of space in any of the provided sections.
Don't fail to specify any affiliations or financial interests in clinical laboratories or other businesses as required.
Don't overlook the requirement to list any partners or the specific names of colleagues providing office coverage.
Don't assume information from a previous application or form is automatically transferred; every field must be completed.
Don't rush through filling out the form without double-checking for errors or omissions.

Misconceptions

When navigating the landscape of medical licensing and practice applications in New Jersey, the Universal Physician Application form plays a critical role. However, various misconceptions surround this document, leading to confusion and potential mistakes by applicants. Here, we aim to clarify the most common misconceptions concerning the New Jersey Universal Physician Application form.

Only for New Applicants: A common misunderstanding is that the New Jersey Universal Physician Application form is exclusively for physicians new to practice in New Jersey. In reality, it is utilized for both initial applications and by those physicians seeking to update their records or apply for recredentialing with healthcare entities.
Personal Information is Optional: Every section requesting personal information is essential. Some applicants incorrectly believe that providing detailed personal information, such as previous names or social security numbers, is optional, not recognizing that this information is crucial for identity verification and background checks.
One Form Fits All: The assumption that one application suffices for all licensing and credentialing in New Jersey is incorrect. While the Universal Physician Application is comprehensive, specific situations or institutions may require additional documents or separate applications.
Professional Liability Section is for Currently Insured Only: Applicants sometimes think the professional liability insurance section is only for those currently holding an insurance policy. However, it is also necessary to provide past insurance details to offer a complete coverage history.
Board Certification Details are for Specialty Practice Only: There is a misconception that only specialists need to fill out the board certification section. All applicants, regardless of specialty, must provide board certification information if applicable, including primary care physicians.
Work History Gaps are Negligible: Some applicants overlook the importance of explaining gaps in their work history. Clarifying any period of unemployment or time away from practice is crucial for a thorough review process.
References from Any Source Are Acceptable: The belief that references can come from any professional contact is mistaken. The form specifies that references should not be partners in the applicant's group practice nor relatives, emphasizing the need for unbiased professional endorsements.
Hospital Privileges Section is Only for Current Affiliations: Another common error is thinking the hospital privileges section requires information solely about current hospital affiliations. In fact, the form requests details on all affiliations, past and present, to form a comprehensive privilege history.
Electronic Submission without Signature is Sufficient: A digital era misconception is that electronic submission of the application negates the need for a signature. The form requires a handwritten signature, even if the application is initially completed electronically, to certify the accuracy of the provided information.
Immediate Processing Time: Applicants often expect immediate processing of their applications once submitted. Processing times can vary significantly based on various factors, including the completeness of the application and the workload of the reviewing body.

Understanding and addressing these misconceptions are vital steps toward a successful application process. It ensures that applicants prepare their submissions thoroughly, adhering to all requirements, which can facilitate smoother credentialing and licensing procedures.

Key takeaways

Filling out the New Jersey Universal Physician Application requires a comprehensive approach, attention to detail, and an understanding of its various sections. Here are six key takeaways to ensure the process is handled efficiently and effectively:

Complete personal and professional information accurately: This includes not only basic personal information but also detailed professional credentials such as degrees, certifications, and licensure in all states where the applicant has held or holds a license. It’s important to type or print clearly to avoid errors that could delay processing.
Disclosure of all practice locations: Given the wide array of services and specialties a physician might provide, accurately listing all current and prospective practice locations, including the primary service type (Primary Care, Specialist, Non-Primary Care Specialist) and the corresponding Tax ID numbers, is crucial for directory listing and billing purposes.
Detail post-graduate education and training: Including comprehensive details about internships, residencies, fellowships, and any additional graduate-level education helps provide a full picture of the physician’s qualifications and specialty areas.
Clarify board certification status and specialties: Clearly indicating whether you are board-certified, in which specialty, by which board, and the dates of certification or recertification is necessary. For those not board certified, providing forthcoming plans for certification or reasons for not pursuing it is important.
Professional liability insurance coverage must be current: Demonstrating proof of malpractice insurance or self-insurance, with detailed information about the coverage amount and the insurance carrier, is a non-negotiable requirement, signaling compliance and responsibility.
Work history and references: A chronological work history since the completion of training, along with gaps explained, and providing professional references, are key to verifying a physician’s experience and standing in the medical community.

Adhering to these key points ensures the application is completed comprehensively, facilitating a smoother verification process and supporting the applicant’s credentials for consideration in the medical community. It’s always advisable to review the entire application for completeness and accuracy before submission, ensuring that all attachments and supplementary information are included as necessary.

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