1. (a) The application described in OAC 310:002-15-2(b) is intended for use pursuant to Title 63 O.S. Supp. 1998, Section 1-106.2.

2. (b) The uniform application for credentialing of providers requests the following:

   1. (1) personal information;
   2. (2) education, including medical, dental and professional schools;
   3. (3) training, including internships, residencies, fellowships and preceptorships;
   4. (4) professional licenses;
   5. (5) certifications and registrations;
   6. (6) academic appointments;
   7. (7) health care affiliations;
   8. (8) other professional work history;
   9. (9) current professional practice;
   10. (10) office billing information;
   11. (11) attestation;
   12. (12) copies of required documents; and
   13. (13) any additional information needed to answer all questions fully.

Added at 16 Ok Reg 901, eff 1-5-99 (emergency)

Added at 16 Ok Reg 1389, eff 5-27-99

Amended at 17 Ok Reg 687, eff 12-16-99 (emergency)

Amended at 17 Ok Reg 2034, eff 6-12-00