• A completed Disclosure Question form with explanations for any “Yes” answers.
• A release authorizing Medica to contact and review the records of any medical society, hospital, insurance company or other entity, institution or organization that does or may have records concerning the applicant and releasing from liability any such entity, institution or organization that provides information as part of the application processThe individual practitioner is also advised that the National Practitioner Data Bank will be queried as part of the application review process and that a report may be submitted to appropriate state licensing boards and/or the Data Bank in the event that the application is denied for issues related to competence.
  

Required attachments
Attach the following documents to the application:

• A copy of current state licensure or registration for the state in which the individual practitioner will practice.
• A copy of current Drug Enforcement Administration (DEA) certificate, for applicable practitioners.
• A copy of the face sheet of the individual practitioner’s current general and professional liability insurance policy ($1,000,000 per claim/$3,000,000 aggregate), listing policy coverage dates for each participating practice site. Entities covered by Minnesota Statute 466.06 (Tort Liability, Liability Insurance Section) need to include documentation to support coverage under this Statute (e.g. letter or memo).
• Allied Health Professionals: A copy of certification (as applicable to occupation).

 
Return the completed application to the Credentialing Department with all appropriate attachments. Applications should be submitted at least two months prior to an individual practitioner’s start date at a clinic.

*Note: The Authorization and Release, and Disclosure Questions must be completed by the applicant, not clinic/office staff.


Mail completed applications with attachments to: 
    Medica Credentialing Department 
    Mail Route CP412 
    PO Box 9310 
    Minneapolis, MN 55440-9310


Locum tenens
If the individual practitioner is practicing as a locum tenens whose assignment is 60 days or less, he or she may complete Medica’s Locum Tenens Application in lieu of the Minnesota Uniform Credentialing Application. If the assignment is greater than 60 days, the applicant must complete the Minnesota Uniform Credentialing Application.



*Providers may not bill for Medica patients until their credentialing process has been completed.


Return to Credentialing Information.