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State Application
Questions, Instructions and Information
The universal credentialing (and recredentialing) application, created and maintained by the ACPCI, is meant to be a convenience to providers in Oregon, eliminating the need to complete multiple unique applications for each health plan, hospital, insurer, etc. However, credentialing is not currently governed by the state.
 
The state cannot give legal advice or give direction about how to answer any questions on the applications. Please use your best professional judgment, contact the health related organization responsible for credentialing or seek legal counsel, as appropriate.
 
Where to send completed applications? 
Please send completed applications to the health care related organization where you have applied. Due to confidentiality issues, applications received by this office must be shredded.

Technical questions:
For questions about technical issues such as credentialing form versions, including formatting issues and software compatibility, please contact Dorothy Allen, 503.373.1985.


Important Instructions:
  • Complete the application in its entirety.
  • Keep an unsigned and undated copy of the application on file for future requests.
  • When a request is placed, send a copy of the completed application to the health care related organization to which you are applying, making sure that all information is complete, current and accurate.
  • Please sign and date:
    • Attestation Questions page
    • Authorization and Release of Information Form
    • Attachment A, Professional Liability Action Detail, if applicable
  • Each page of the application requires the applicant’s initials and the date on which the application was last reviewed.
  • Identify the health care related organization(s) to which this application is being submitted in the space provided below.
  • Attach copies of the documents requested each time the application is submitted.
  • If a section does not apply to you, please check the provided box at the top of the section.
  • Mail application to the requesting organization(s).

Warning:
Modification to the wording or format of the Oregon Practitioner Credentialing Application will invalidate the application.

Licensing Questions:
Physician licensing questions should be directed to the Oregon Medical Board 
Other Boards (This list is not inclusive):
Medical Doctor (MD) •Doctor of Osteopathy (DO)  •Doctor of Podiatric Medicine (DPM)  
  •Acupuncturist (LAc)    •Physician Assistant (PA)        •Doctor of Chiropractic (DC)
 
All other professions should contact your professional licensing department.  Please see the alphabetical listing of state agency information.

2012 Application - Effective May 1, 2012
MS Word Version
• 2012 MS Word - Credentialing Application Form 
• 2012 MS Word - Credentialing Application Form with Glossary 
• Attachment A (pdf) 
  
  

Adobe PDF Version
• 2012 Adobe pdf - Credentialing Application Interactive Fillable Version
• 2012 Adobe pdf - Credentialing Application Interactive Fillable Version With Glossary
• Attachment A (pdf)  

For Best Results
Please download the file to your computer.
From the menu bar, select:  Tools, Macro, Security, Medium
Additional downloading tips 

 

Unprotected Forms Available On Request
Disclaimer:
If you are provided with an unprotected copy of the Oregon Practitioner Credentialing Application, understand that you are responsible for assuring that no changes to content or format are made.  Any such changes invalidate the application; the Office of Health Policy and Research and the Advisory Committee on Practitioner Credentialing Information accept no responsibility for the consequences of such changes.
 

Requests
Email Dorothy Allen, include "Unprotected Application" in the subject line.