16
2) Current and complete professional liability information on the application and provide a copy of your
current malpractice insurance face sheet.
3) Current and complete hospital affiliation information on the application and a copy of your current
appointment or reappointment letter.
4) If no hospital privileges and your specialty warrants hospital privileges, a letter from you detailing your
coverage arrangements and a letter from the physician who will admit for you.
5) Five years of work history (month/year format) documented on the application or on current curriculum
vitae with any gaps of more than 6 months explained and gaps of one year or more explained in writing.
6) A signed and dated Provider Agreement. Upon acceptance, an executed copy will be returned to you for
your files.
7) Completed and signed W-9 form.
8) Bravo Health conducts an office site visit at Primary Care and OB/GYN offices. This requirement is
waived for new physicians joining an existing practice.
All applications for participation with Bravo Health will be reviewed by the designated Bravo Health
Medical Director and Physician Advisory Credentialing Committee (PACC). Applications will be
reviewed on an individual basis
The criteria stated below are the minimum standards, and meeting these criteria is not sufficient in and
of itself for acceptance. Bravo Health maintains the right to limit the Provider network according to its
needs. The credentials process is a vital part of the Bravo Health Quality Assessment program and is an
essential tool to assure that the care delivered is of optimal quality using the resources available.
All information submitted to Bravo Health for both the initial credentialing and re-credentialing
processes will be considered by the PACC prior to making a decision regarding acceptance, denial, or
termination.
CREDENTIALS CRITERIA
1. Physicians must have obtained a Doctor of Medicine, Doctor of Osteopathy, Doctor of Medical
Dentistry, or Doctor of Dental Surgery, degree from a medical school accredited by one of the
following: the Liaison Committee on Medical Education (or have obtained a certificate from the
Educational Council for Foreign Medical Graduates-ECFMG), the American Osteopathic
Association (AOA) or the American Board of Oral and Maxillofacial Surgery (ABOMS). Allied
Health Professionals must have graduated from an approved professional degree program for the
specialty they are applying for participation.
2. Physicians must have completed a full residency training program accredited by one of the agencies
listed below in the specialty designated as the individual’s principal type of practice: American
Osteopathic Association (AOA) or the American Dental Association Commission on Dental
Accreditation or the American Medical Association (AMA).
3. Physicians and Allied Health Professionals must have and maintain a current and unrestricted license
to practice medicine granted by each State where he or she has an office listing with Bravo Health.
Any Provider whose license is in a probationary status is not eligible for Membership.
