Clinical Department Checklist

The following are tips on checking Initial/Recredential TDI applications prior to returning them to Credentialing.

All managed care TDI applications have "UT Southwestern Health Systems" indicated in red on the top of each page.

1). Make sure that the application is completed with all pertinent data:
      a. Education and dates
      b. Work history from completion of education
      c. License and certifications
      d. Disclosure questions answered.

2) Please ensure the practitioner initials & dates the bottom of page 11 and signs, prints their name, provides their social security number and dates the middle of page 12.

3) Please ensure the practitioner answers page 9, question #23 correctly.

4) Practitioners must initial and date all corrections made to the application.

5) Please provide current copies of Texas license, DEA, DPS, malpractice insurance and board certification (if applicable).

6) A CV must be enclosed for all practitioners undergoing initial credentialing.

7) All gaps in work history must be clarified in writing.

8)  Malpractice history, if applicable, must be completely disclosed:
     a. Doctor's description of allegations for suit(s)
     b. Dates of filing and conclusion (if applicable).
     c. Current status of suit(s) pending, settled, closed etc.
     d. Amount of money paid on behalf of doctor, if applicable.