Attachment 26 - DHS Health Care Provider Verification Form.pdf

CDP Medical Support Services

Attachment 26

Department of Homeland Security (DHS) e5207 Health Care Provider

Credential Verification Form

DEPARTMENT OF HOMELAND SECURITY

HEALTH CARE PROVIDER CREDENTIALING FORM

Instructions: Complete ALL applicable fields. All DATES must be in the following format mm/dd/yyyy

DHS Component:

Provider Name (First, Middle, Last):

Home Address:

City: State: Zip Code:

Work Address:

City: State: Zip Code: Date of Birth (MM-DD :)YYYY-

Home Phone:

Work Phone: Email Address:

Provider Type: Professional School Name:

Professional School Graduation Year:

Post Graduate Institution(s): Completion Year:

State License (Name of State): License Number: Date Issued: Exp. Date:

State License (Name of State): License Number: Date Issued: Exp. Date:

National Certification: Certificate Number: Date Issued: Exp. Date:

National Registration: Registration Number: Date Issued: Exp. Date:

Board Certification (Specialty): Certificate Number: Date Issued: Exp. Date:

Federal DEA (Type): Registration Number: Date Issued: Exp. Date:

National Provider Identification: Registration Number: Date Issued: Exp. Date:

BLS EXPIRES mm/yyyy: ACLS EXPIRES mm/yyyy:

**EMAIL A COPY OF STATE LICENSE, BLS/CPR, ACLS, NATIONAL CERTIFICATION, BOARD CERTIFICATION, NATIONAL REGISTRATION, FEDERAL DEA/STATE CSR, etc. Contractors MUST also include Resume or CV

HEALTHCARE APPLICANT QUESTION AND VERIFICATION: Have you ever had any healthcare certifications, licenses or clinical privileges withheld, suspended, revoked, or denied, or have you surrendered, or allowed a license or certificate to expire or lapse as a result of an investigation or disciplinary action?

Yes

No

DHS Form e5207 (08/2020)

Contractor or Federal:

Other Names Used:

City:State: Degree Awarded:

City: State:

Country

Country:Post Graduate Type

I understand that all information on this application is correct to the best of my knowledge and is subject to verification

Provider Applicant Signature:

COMPONENT APPROVAL and ENDORSEMENT

As an authorized Component Supervisor, I recommend that this provider be credentialed by the DHS OHA to function at the following Provider Type:

Authorized Supervisor Signature:

Authorized Supervisor Name: Authorized Supervisor Email:

**** CONTRACTORS ARE REQUIRED TO ATTACH SCANNED COPIES OF THEIR ACLS, RESUME and/or CV.

PRIVACY ACT STATEMENT

AUTHORITY: Section516(c) (3) of the Post Katrina Emergency Management and Reform Act, P.L. 109-295 6 U.S.C §321e(c).

PRINCIPAL PURPOSE(S): DHS will use this information to verify the credentials of DHS employees that provide health care services as part of their Component' mission or incidental to their ongoing operations. Upon verification of medical credentials, the information will be used to approve the employee as a DHS health care provider.

ROUTINE USE(S): The information will be used and disclosed by DHS in accordance with, OPM-GOVT-1, General Personnel Records 71 FR 35341. For example, the information may be disclosed to federal, state, local, and professional licensing boards, or a non-government entity which maintains records concerning individuals' employment histories or concerning the issuance, retention, or revocation of licenses, certifications.

DISCLOSURE: Furnishing this information is voluntary; however, failure to furnish the requested information will prevent DHS from permitting you to function as an authorized DHS health care provider.

DHS Form e5207 (08/2020) Page 2 of 2

1. Instructions: You may use the "Submit via Email" button below to SAVE and EMAIL your completed form.

2. "SUBMIT via EMAIL" you will be requested to complete all required fileds that are blank such as your Digital

3. "SUBMIT via EMAIL" will allow you to save a copy of your completed form for your records. Please be aware of where this file is saved on your machine.

4. EMAIL COMPLETED FORM AND SCANNED COPIES OF CERTIFICATES TO :Credentialing@hq.dhs.gov

5. "PRINT" will open the dialog box for the local printer configured for your device.

6. "PRINT" or SAVE a copy of the completed form for your records.

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