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Blank California Participating Practitioner PDF Form

The California Participating Practitioner form is a document that healthcare practitioners must complete to provide information about any professional liability lawsuits or arbitrations they have faced in the past seven years. This form ensures that all relevant details regarding pending, settled, or concluded actions are disclosed, allowing healthcare organizations to evaluate a practitioner's application effectively. If you need to fill out this form, please click the button below.

Article Guide

The California Participating Practitioner form is an essential document for healthcare professionals seeking to engage with participating healthcare organizations. This form, particularly Addendum B, focuses on professional liability actions, requiring practitioners to disclose any pending or concluded lawsuits or arbitrations from the past seven years. It emphasizes the need for thoroughness, asking practitioners to provide detailed information about each case, including the patient's name, the nature of the allegations, and the outcome of the legal proceedings. Practitioners must also indicate whether they had insurance coverage during these actions and, if applicable, provide contact details for their legal representatives. The form ensures that all questions are answered completely to avoid delays in the application process. It culminates in a certification that the information provided is accurate and grants permission for the healthcare organization to verify the applicant's malpractice insurance and claims history, all while maintaining confidentiality. This careful documentation helps healthcare organizations assess the qualifications and risk profiles of their practitioners, ultimately supporting a safer healthcare environment for patients.

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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:
			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

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.

Amount paid 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

Version 1.2012

➤ PDF File

Form Specifications

Fact Name	Description
Purpose of the Form	The California Participating Practitioner form collects information about any professional liability lawsuits or arbitrations involving the practitioner in the past seven years.
Required Information	Practitioners must provide details such as their name, patient information, case status, and any insurance coverage related to the lawsuits.
Multiple Claims	If there are multiple lawsuits or arbitrations, practitioners must photocopy the addendum and complete a separate form for each case.
Confidentiality	The information provided will be kept confidential and shared only for credentialing and peer review purposes.
Governing Law	This form is governed by California Business and Professions Code, specifically sections related to healthcare practitioners and professional liability.

California Participating Practitioner: Usage Guidelines

After gathering the necessary information, you can proceed to fill out the California Participating Practitioner form. This form requires detailed information about any professional liability lawsuits or arbitrations you have been involved in over the past seven years. Ensure that you answer all questions completely to avoid any delays in processing your application.

Gather Information: Collect all relevant details about any lawsuits or arbitrations, including dates, case numbers, and the names of involved parties.
Complete Practitioner Identifying Information: Fill in your last name, first name, and middle name in the designated sections.
Fill Out Case Information: Provide the patient's name, city, county, and state where the lawsuit was filed. Indicate the patient's gender and date of birth.
Enter Court Case Number: If known, write down the court case number associated with the lawsuit.
Detail Allegations: Describe the date of the alleged incident and the location (hospital, your office, etc.). Specify your relationship to the patient (e.g., attending physician, surgeon).
Insurance Information: Indicate whether an insurance company provided coverage for the lawsuit. If yes, include the company name, contact person, phone number, and claim identification number.
Attorney Information: If applicable, provide the names and phone numbers of your attorney(s). Include a fax number for your attorney to receive this document.
Status of Lawsuit/Arbitration: Check the appropriate status of the lawsuit or arbitration, such as ongoing, settled, or judgment rendered.
Summarize the Circumstances: Write a narrative detailing the circumstances of the action, including patient condition, treatment dates, and outcomes. Attach additional sheets if necessary.
Certification: Read the certification statement carefully, then sign and date the application at the bottom.

Your Questions, Answered

What is the purpose of the California Participating Practitioner form?

The California Participating Practitioner form is designed to collect essential information from healthcare practitioners who are applying to participate in a healthcare organization. It helps organizations assess the practitioner's qualifications, including their professional liability history. This ensures that the organization maintains a high standard of care and safety for its patients.

Who needs to complete Addendum B of the form?

Addendum B must be completed by any healthcare practitioner who has been involved in a professional liability lawsuit or arbitration within the past seven years. This includes cases that are pending, settled, or otherwise concluded. Each lawsuit or arbitration requires a separate form to ensure that all relevant details are captured accurately.

What information is required on Addendum B?

When filling out Addendum B, practitioners must provide specific information, including their name, the patient's name, the location and date of the alleged incident, and the status of the lawsuit or arbitration. Additionally, details about any insurance coverage related to the case must be included, along with a summary of the circumstances surrounding the action.

What if I have no pending or settled claims to report?

If there are no pending or settled claims to report, practitioners can simply check the designated box on the form. This will indicate that there are no professional liability lawsuits or arbitrations to disclose, and they will need to sign below to attest to this statement.

How should I summarize the circumstances of a lawsuit or arbitration?

In the summary section, practitioners should provide a detailed narrative of the case, particularly if it involves patient care. This includes the patient's condition and diagnosis at the time of the incident, a description of the treatment rendered, and the patient's condition following treatment. If more space is needed, additional sheets can be attached.

What happens to the information provided in this form?

The information submitted in the California Participating Practitioner form is used solely for the purpose of evaluating the practitioner's application for participation in the healthcare organization. It is treated confidentially and shared only in the context of legitimate credentialing and peer review activities. Practitioners also authorize their attorney to discuss relevant information regarding their case with the healthcare organization.

Common mistakes

Incomplete Information: Failing to answer all questions completely can lead to delays. Every section must be filled out accurately.
Missing Attachments: If there are multiple lawsuits, applicants often forget to photocopy the Addendum B. Each lawsuit requires a separate form.
Incorrect Case Status: Applicants sometimes misreport the status of their lawsuits. It's crucial to select the correct option, whether ongoing, settled, or dismissed.
Insufficient Details: Providing vague descriptions of the case can cause issues. A clear narrative of the circumstances, including patient care details, is essential.
Omitting Contact Information: Not including the insurance company or attorney's contact details can hinder the application process. Accurate contact information is necessary for follow-up.

Documents used along the form

The California Participating Practitioner form is an essential document for healthcare providers seeking participation in certain healthcare organizations. Alongside this form, several other documents may be required to ensure a comprehensive evaluation of a practitioner's qualifications and history. Below is a list of five forms and documents commonly used in conjunction with the California Participating Practitioner form.

California Participating Physician Application - Addendum A: This addendum collects detailed information regarding the practitioner's qualifications, including education, training, and board certifications. It serves as an essential component of the overall application process.
Professional Liability Insurance Verification: This document confirms the practitioner's current malpractice insurance coverage. It provides details such as the policy number, coverage limits, and the insurance provider’s contact information, ensuring that the practitioner is adequately protected against potential claims.
Credentialing Application: Often required by healthcare organizations, this application gathers comprehensive information about the practitioner's education, work history, and professional references. It helps organizations assess the practitioner's qualifications and suitability for practice within their facilities.
Background Check Authorization Form: This form authorizes a background check on the practitioner, which may include criminal history, professional misconduct, and verification of licenses. It is a critical step in ensuring patient safety and maintaining the integrity of the healthcare organization.
Malpractice Claims History Report: This report summarizes any past malpractice claims against the practitioner. It includes details about the nature of the claims, outcomes, and any settlements. This information is vital for assessing the practitioner's risk profile and professional conduct.

Each of these documents plays a crucial role in the credentialing process for healthcare practitioners in California. By providing detailed and accurate information, practitioners can facilitate a smoother application process and ensure that they meet the necessary requirements for participation in healthcare organizations.

Similar forms

The California Participating Practitioner form shares similarities with several other documents commonly used in healthcare and legal settings. Below are four documents that have comparable elements and purposes:

Medical Malpractice Insurance Application: Like the Participating Practitioner form, this application requires detailed information about any past claims or lawsuits against the practitioner. Both documents aim to assess the practitioner's professional liability history to ensure patient safety and quality of care.
Credentialing Application: This document is used by healthcare organizations to verify the qualifications and background of healthcare providers. Similar to the Participating Practitioner form, it collects information about any legal actions, ensuring that only qualified practitioners are granted privileges to practice.
Claims History Disclosure Form: This form requests a comprehensive account of any claims made against a practitioner. It parallels the California Participating Practitioner form by focusing on the disclosure of past professional liability actions, thus providing insight into the practitioner's risk profile.
Peer Review Documentation: This document is part of the peer review process that evaluates a practitioner's performance and conduct. It shares a common goal with the Participating Practitioner form: to maintain high standards in healthcare by reviewing any past legal issues that may affect the practitioner's ability to provide care.

Dos and Don'ts

When filling out the California Participating Practitioner form, it's essential to follow certain guidelines to ensure accuracy and completeness. Here’s a list of things you should and shouldn't do:

Do provide complete and accurate information for each question.
Do photocopy the form for multiple lawsuits or arbitrations.
Do include all relevant details about the case, including dates and patient information.
Do specify your relationship to the patient clearly.
Do sign the form to attest to the accuracy of the information provided.
Don't leave any questions unanswered, as this can delay your application.
Don't provide vague descriptions; be detailed in your narrative of the case.
Don't forget to include your attorney's contact information if you want them to be contacted.
Don't use a stamp for your signature; it must be handwritten.

Misconceptions

Misconception 1: The form only applies to lawsuits that have resulted in a settlement or judgment.

This is incorrect. The California Participating Practitioner form requires information about all professional liability lawsuits or arbitrations, regardless of their current status. This includes pending cases, settled cases, and those that have been resolved without any payment.

Misconception 2: Only lawsuits involving significant financial settlements need to be reported.

All lawsuits or arbitrations must be reported, regardless of the financial outcome. The form emphasizes that it is necessary to disclose any case where the practitioner was named a party, irrespective of whether any payment was made on their behalf.

Misconception 3: Completing the form is optional if there are no pending claims.

This is misleading. While practitioners can check a box indicating there are no claims to report, they still need to complete the form fully, including their identifying information. This ensures that the application is processed without delays.

Misconception 4: The form is only relevant for physicians.

The form applies to all healthcare practitioners who may be involved in professional liability actions. This includes various roles such as surgeons, consultants, and attending physicians. Each practitioner must complete the form as it pertains to their specific situation.

Key takeaways

When completing the California Participating Practitioner form, it is essential to pay attention to several key aspects to ensure a smooth application process.

Complete All Sections: Every question on the form must be answered fully. Incomplete submissions can lead to delays in processing your application.
Multiple Actions Require Separate Forms: If you have more than one pending or settled professional liability lawsuit, you must photocopy the addendum and fill out a separate form for each case.
Provide Detailed Case Information: Include comprehensive details about each lawsuit or arbitration, such as the patient's name, the nature of the allegations, and any insurance coverage involved.
Sign and Authorize: Ensure you sign the form to attest to the information provided. Additionally, authorize your attorney to discuss relevant details with the healthcare organization.